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COPYRIGHT DEPOSIT. 



POSTOPERATIVE TREATMENT 



MORSE 



REVIEWS OF PREVIOUS EDITION. 



From The British Medical Journal.— " There can be no doubt that 
'Postoperative Treatment' forms a handsome and, what is better, a 
handy volume after the type of the best current trans-Atlantic medical 
works. Dr. Morse rightly insists that operating is taught too much 
and postoperative treatment too little. * * * It is written well up 
to date and is full of detail, therefore it is admirably adapted for 
reference. Thus, every student has not the opportunity of assisting 
at an excision of the Gasserian ganglion. Hence, it is advisable that 
when qualified he should be aware that steps should be taken after 
operation to avoid a collection of blood between the dura mater and 
the flap. The management of amputations, where after-treatment 
is all-important, is discussed as fully as it deserves. * * * The 
formulas for foods and prescriptions are very useful for their pur- 
pose. * * * Dr. Morse, however, shows that he can relate varia- 
tions of method in a really instructive and intelligible manner, in 
those pages devoted to the preparation of the field of operation by 
different surgeons. Dr. Joseph Price's pungent satire on unintelli- 
gent drainage and incisions is, we all must allow, well worth perusal. 
Still what the reader wants is Dr. Morse's opinion, for it is worth 
having, and more than sufficient for those practical ends for which 
his book was designed." 

From American Medicine. — " The author gives an epitome of the 
different methods in use by various surgeons -in their treatment of 
postoperative conditions. Throughout, this is supplemented by the 
author's own experience. He has treated the subject on broad lines, 
taking up, first, the general principles of care in such conditions, 
then particularized, treating of the conditions following surgical pro- 
cedures in the various regions of the body. The author not only 
discusses the care of the wound itself, but also the general care of 
the patient." 

From The Railway Surgical Journal. — " The attending surgeon in 
our large hospital operates; the interne dresses and looks after the 
postoperative needs. The latter knows little or nothing of this pro- 
cedure, aside from what he has learned from his immediate prede- 
cessor. We have seen some of the results. And yet it seems to the 
reviewer that this stage is far more important than the operation 
itself. The purpose of ' Postoperative Treatment' is to aid the un- 
fortunate who attends to this portion of the treatment. * * * The 
work as a whole is superior. It fills a place so long and so shame- 
fully disregarded. The book deserves a wide circulation. The 
hospital interne and the surgeon who dresses his own cases will give 
it a hearty welcome." 



POSTOPERATIVE TREATMENT 



AN EPITOME OF THE GENERAL MANAGEMENT OF POST- 
OPERATIVE CARE AND TREATMENT OF SURGICAL CASES 
AS PRACTISED BY PROMINENT AMERICAN AND EUROPEAN 
SURGEONS. TOGETHER WITH SUGGESTIONS CONCERNING 
THE TECHNIC OF CERTAIN OPERATIONS WITH A 
VIEW TO SECURING BETTER POSTOPERATIVE RESULTS 



BY 

NATHAN CLARK MORSE, A.B., M. D. 

SURGEON-IN-CHIEF TO "EMERGENCY HOSPITAL," ELDORA, IOWA; DISTRICT SURGEON, CHICAGO & 
NORTHWESTERN AND IOWA CENTRAL RAILWAYS; EX-PRESIDENT IOWA STATE ASSOCIA- 
TION OF R. R. SURGEONS; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION, 
PAN-AMERICAN MEDICAL CONGRESS, INTERNATIONAL ASSOCIATION 
OF R. R. SURGEONS, ETC. 



Second Edition, Revised and Enlarged 



CONTAINING 5 PLATES AND 
175 OTHER ILLUSTRATIONS 



PHILADELPHIA 

BLAKISTON'S SON & CO 

1012 WALNUT STREET 
1907 



■ M z%2~ 



UBRARY of CONGRESS 
Two Copies Received 

APK 12 1907 

s Copyright Entry . 

CUSS A XXC.No. 
COPY B. ' ' 



Copyright, 1907, by P. Blakiston's Son & Co. 



Printed by 

The Maple Press, 

York, Pa. 



TO 
ELBERT WARREN CLARK, M. D. 

ONE OF THE GRAND SURGEONS OF IOWA 

AS A TOKEN OF FRIENDSHIP AND LONG ASSOCIATION 

THIS WORK IS RESPECTFULLY INSCRIBED 

BY THE AUTHOR 



PREFACE TO SECOND EDITION 



The exhaustion of entire First Edition within a year following its 
appearance is a source of much gratification, and leads the Author to 
believe that his effort to produce a work of practical value to the pro- 
fession has been in a measure accomplished. 

The Second Edition has been in part carefully rewritten and all 
recent advances which in the Author's personal experience are worthy of 
acceptance (such, for instance, as Moorhof's method of treating 
tuberculous joints and bone cavities — Mayo Robson's postoperative 
treatment of operations on gallbladder and ducts — Joseph Bloodgood's 
treatment following thyroidectomy — Fenwick on vital points in pros- 
tatectomy — Mayo on removal of varicose veins — Bartlett on post- 
operative hernia etc.) have been added, together with several new 
illustrations which will tend to render the work of still greater value. 

Nathan Clark Morse. 

Eldora, Iowa, March i, 1907. 



Vll 



PREFACE TO FIRST EDITION 



The average graduate in surgery knows but little concerning the 
proper management of postoperative treatment of surgical cases; most 
of his time in college being engrossed with what appears to be the more 
important matter of surgical technic, pathology and bacteriology. 
He realizes the great importance of minor details only when, in actual 
practice, he is thrown upon his own resources, and the skill he may 
then acquire is obtained through personal experiences with suffering 
patients. He may visit the greatest clinics and witness the most 
brilliant operative technic, but the curtain falls and his observation 
ceases on the removal of the patient from the operating amphitheatre. 

I have long regarded postoperative care and treatment as being 
equal, if not of greater importance, than mere brilliant technic. 
Faulty technic may complicate or retard recovery, but faulty post- 
operative management has robbed many surgeons of what should have 
been successful results. 

The practice of asepsis and antisepsis has removed many complica- 
tions which heretofore so commonly followed surgical operations. But 
from my own experience and the observation of cases occurring in the 
practice of some of our best surgeons I am forced to conclude that 
infection is often unavoidable and frequently occurs under the most 
favorable circumstances. It is these cases that frequently tax to the 
utmost the skill and ingenuity of the postoperative attendant. 

Surgeons differ radically over the management of similar cases, each 
basing his opinion on conclusions evolved from personal experience, 
hence the meagre information given this important subject by the 
average modern text-book is frequently conflicting and therefore a dis- 
appointment to the student and busy surgeon. 

I have long felt the need of a work of this character, and have at- 
tempted to compile a rational system, a text-book or guide to the proper 
postoperative management or treatment, which, so far as I have been 
able to ascertain, is the first work devoted exclusively to this subject 
brought before the profession. 

ix 



X PREFACE TO FIRST EDITION. 

The character of the work admits of little originality. What follows 
is, therefore, an epitome of the various methods used or adopted by 
modern American and European surgeons, much of the information 
being derived from personal letters, text-books, medical journals, etc., 
supplemented when possible by what my own experience has led me to 
believe is rational and practical. 

I have intentionally omitted all reference to surgical pathology and 
bacteriology, confining myself as strictly as possible to the subject 
under consideration. 

Nathan Clark Morse. 

Eldora, Iowa, October i, 1905. 



% 



CONTENTS. 



CHAPTER I. 



PAGE 

PREPARATION OF THE PATIENT FOR SURGICAL OPERATION,. . . . 1-6 

General remarks; rationale of preparatory treatment as advocated by the 
author, i. — When complicated by phthisis, Bright's disease, jaundice, dia- 
betes, etc., 2. — Remedies usually employed to overcome constipation, debil- 
ity, anemia, etc., 2. — Kelly's purgative draft, 2. — Method of preparation 
for laparotomy. Franklin H. Martin, 3. — A. J. Ochsner method, 4; Joseph 
Price method, 4; Sir Frederick Treves method, 6. 

Preparation of Field of Operation, 7-8 

General remarks, 7. — For operation on eye, 8; mouth, nose, and throat, 8. — 
Mayo's preparation for stomach operations, 8. — Preparation of cervix and 
uterus, 9; bladder, urethra, and kidneys, 9. 

Preparation of Field by Different Surgeons, 9-18 

Howard Kelly's method, 9. — Joseph Price method, n. — Method of 
Nicholas Senn, n. — Treves' method, 13. — Keen's method for cerebral 
operation, 14. — Ochsner's method, 15. — Method of Robert T. Morris, 15. 
— Final considerations, 16. — Solutions to be used in the peritoneal cavity, 
16. — Remarks on drainage by Joseph Price, 17. , 

CHAPTER II. 
POSTOPERATIVE WOUND SUTURES, DRAINAGE AND DRESSINGS, 19-31 

Postoperative wound sutures, 21. — Character of sutures, 21. — Double 
ligature of arteries, 21. — Method advocated by author for closure of ab- 
dominal wounds, 21, 22. — Lister's stitches of relaxation or button sutures, 
21. — Irrigation of wound during operation, 22. — Objections thereto, 22. — 
Remarks on drainage of wounds, 29. — Material for drainage, 30. — Anti- 
septic gauzes recommended by various surgeons, 30, 31. — Essentials requi- 
site for good wound dressing, 30. 

CHAPTER III. 
POSTOPERATIVE COMPLICATIONS, 33 - 7 6 

Postoperative temperature and treatment, 35. — Diarrhea, 35. — Postopera- 
tive infection, 36; treatment of, 38. — Hemorrhage, 39. — Bleeding from 
bones, 40. — Hemophilia, 40. — Secondary hemorrhage, 40. — Hemorrhage 
after nasal operations, 41. — Hematemesis, 42; prognosis and treatment, 43. 
— Intestinal paresis, or pseudo-ileus, 43; causes of, 44; symptoms of, 45; 
Wiggin's method of treatment, 46; use of eserin as recommended by Arndt, 
46. — Postoperative lung complications, 47. — Pneumonia, symptoms, and 
treatment, 48. — Rochester's method of treatment, 49. — Embolism and 
thrombosis, 51. — Gangrene, 54. — Cystitis and treatment, 55. — Neurasthe- 
nia, 58. — Postoperative insanity, 62. — Delirium, 63. — Jaundice 63. — Ery- 
sipelas, 64. — Peritonitis, 67. — Postoperative bed-sores and treatment, 75. 

xi 



Xll CONTENTS. 

PAGE 

CHAPTER IV. 

GENERAL PRINCIPLES OF AFTER-TREATMENT AND POSTANES- 
THETIC COMPLICATIONS, 79-97 

General remarks concerning care of patient immediately following opera- 
tions, 79. — Pallor and feebleness of pulse following anesthesia, 80. — Pos- 
ture of patient, 80. — Prone position, 81. — Fowler's semi-erect position, 
81. — Lateral position, 82. — Postoperative nausea and vomiting, 83; special 
method of prevention and treatment, 84. 

Postoperative Surgical Shock, 8 5-94 

General consideration of shock, 85. — General symptoms, 86. — Preventive 
measures, 87. — Surgical shock due to vasomotor depression, nervous ex- 
haustion, without serious hemorrhage, 89. — Treatment, 89. — Acute dilata- 
tion of the stomach, symptoms and treatment of, 94. — Postoperative thirst, 
95. — Morphin, indications for its postoperative emplovment, 96. 

CHAPTER V. 

TREATMENT OF ASEPTIC AND SEPTIC WOUNDS, 100-109 

Postoperative treatment of wounds, 100. — Treves' method of wound treat- 
ment, 103. — Tillman's paper dressing, 103. — Pryor's treatment of septic con- 
ditions after plastic operations, 105. — Principles which govern the treat- 
ment of infected wounds, DaCosta, 106. — Sterilized olive oil in septic 
wounds, 108. 

CHAPTER VI. 

ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT, 1 13-135 

Hypodermoclysis, 113. — Formula for normal salt solutions, 113. — Intra- 
venous injections, 115. — Character and temperature of solutions for, 116. 
— Rectal alimentation, 117. — Philadelphia General Hospital formula for 
rectal feeding, 119. — Subcutaneous feeding, 120. — Inunctions for, 120. — 
Bandaging, principles of, and various methods, 120. — Support and com- 
press bandaging, 121. — Elizabeth Trotter abdominal bandage. 127. — Mun- 
ger's invalid bed, 129. — Crosby's bed, 130. — Sick-bed chair, 130. — Hospital 
lifter, 130, 132. — Medico-mechanical apparatus, 133. 

CHAPTER VII. 

HEALING OF GRANULATING WOUNDS, 139-146 

Kocher's method, 139. — Harmful action of chemical irritants, 139. — Out- 
ten's method to enforce healing, 139. — Skin grafting, 141; Reverdin's 
method, 141. — Thiersch's method, 141; preliminary preparation of surface, 
142. — Operation of grafting, 143. — Cutting of grafts, 143. — Application of, 
144. — Dressings, character of, and method of applying, 144. — Changing 
first dressings, 145. — After-treatment in general, 145. — Transplantation in 
mass, 146; use of Cargile membrane in, 146. 

CHAPTER VIII. 

OPERATIONS, 149-169 

Postoperative treatment of operations on scalp, 149. 

Operations upon the Skull and Brain, 149 

General remarks on postoperative treatment following operation on the 
skull and brain, 149. — Significance of sudden rise of temperature after, 
and treatment, 149. — Complications following operations on brain, 150. — 
Postoperative hernia cerebri, 151. — Trephining, 152; closure of wound, 
method of, 152; after-treatment of, 152. — Methods of preventing post- 
operative brain adhesions, 153. 



CONTENTS. Xlll 

PAGE 

Operations upon the Jaw, 155 

Superior maxilla, excision of, 155. — Excision of lower jaw, after-treatment 
of, method of dressing, feeding, etc., 156. 

Excision of Tongue, 158 

General considerations, 158. — After-treatment, 159, 160. 

Cleft Palate, 162 

After-treatment, Cheyne, 162. — Postoperative complications, 162. — Re- 
sults, 166. 

Hare-lip, 167 

After-treatment of, 167. — Lord Lister's method of dressing and after-treat- 
ment, 167. 

Operations on Nose, 168 

Paraffin injection for deformities, 168. 

CHAPTER IX. 

OPERATIONS (Continued), 173-194 

Tracheotomy, Laryngotomy, After-treatment of, 173 

Jacobson's method, 175. — Dietetics, 176. 
Intubation, 1 76 

O'Dwyer's method, 176. — Time for removal of tube, 178. — Feeding after 

intubation, 179. 

ESOPHAGOTOMY, 179 

After-treatment of, 179. — Davis apparatus in after-treatment, 179. 

Operations on the Thyroid Gland, 180 

Recurrent hemorrhage after, 180. — Bloodgood's method of after-treatment, 
181. — Complications, 181, 182. 

Mastoid Abscess, 182 

After-treatment, 182. — Complications following operation, 183. 

Empyema or Pleurotomy, 183 

Christie's, Jr., method of drainage, 185. — Senn's method of double tube 
drainage and after-treatment, 185. 

Breast Amputation, 188 

After-treatment of, 189. — Bodine's triangular splint and method of dressing 
after, 189. — Author's method of dressing, 191. 

CHAPTER X. 

OPERATION ON THE STOMACH, LIVER, AND INTESTINES, 197-224 

General remarks, 197. — Gastric lavage, importance of, after operation on 
the stomach, Ochsner. 198. — Posture of patient following stomach opera- 
tions, 198. — Employment of laxatives, 198. — Rectal feeding and method of 
introduction of, 199. — Von Leube's formula, 199. — Mayet's pancreatic 
formula, 199. — Rennie's formula for rectal feeding, 200. — Terrier and 
Hartmann's, 200. — Smith's, 200. — Robb's, 200. 

Cholecystotomy, 201 

General consideration of, 201. — Morrison's method of drainage of gall- 
bladder, 202. — Kehr's method of drainage, 204. — Cook's method of drain- 
age, 206. — After-treatment in general, 206. — Mayo Robson's method, 207. 

Abscess of the Liver, 208 

Rhoades' method of procedure in, 208. — After-treatment, 209. — Hepatic 
toxemia, 211. 



XIV CONTENTS. 

PAGE 

Gastrostomy, Gastrostomy, Pylorectomy, 213 

General remarks, 213. — Feeding of patient and after-treatment in general, 
214. — Leakage of gastric juice, 215. 

Intestinal Anastomosis, .215 

Use of Murphy's button and after-treatment in general, 215. 
Colostomy, 217 

Methods of performing, 217. — After-treatment in general, 219. — Treves' 
method and after-treatment, 219. — Martin's method of colostomy for acute 
obstruction, 221. — Senn on intestinal obstruction, 222. — Postoperative en- 
terostomy, 223. 

CHAPTER XI. 

LAPAROTOMY AND OPERATIONS ON THE ABDOMEN, 227-256 

Remarks on postoperative treatment in general, 227. — Abdominal flushing, 
227. — Gruzdeff, drainage, 228. — Care of bowels, 228. — Urine, 229. — 
Laparatomy for septic conditions, 229. — Position of incision, 230. — Lapa- 
rotomy in peritonitis, 231. — McBurney's method in multiple abscess, 231. 
— Postoperative laparotomy for intestinal adhesions, 232. — Prevention of 
postoperative adhesions, 233. 

Aeter-treatment or Abdominal Section, 234 

Method of Treves, 234. 
Appendicectomy, 238 

General principles governing postoperative treatment, 238. — Multiple ab- 
scess following, 239. — After-treatment, method of Ochsner, 241. — Method 
of Brewer, 241. 

Postoperative Treatment of Ovariotomy, Howard Kelly, 243 

Pyosalpinx, 251 

After-treatment of, 251. — Pelvic abscess, method of drainage in, 251. — 
Senn on abdominal drainage in general, 254. — Combined tubular and 
capillary drainage, 256. 

Hernia, 256 

E. Wyllys Andrews' method of operating for, 257. — After-treatment, 259. — 
Complications following, 261. — Postoperative hernia, causes and prevention 
of, 263. — Umbilical hernia, Mayo's method of after-treatment, 266. 

CHAPTER XII. 

OPERATIONS UPON THE UTERUS, VAGINA, BLADDER, AND KID- 
NEYS, 269-290 

Postoperative treatment, of abdominal hysterectomy, 269. — Vaginal hyster- 
ectomy, forceps method, 269; suture method, 270. — Alexander's operation 
for retroversion, postoperative treatment, 272. — Trachelorrhaphy, after- 
treatment of, 272. 

Nephrotomy, Postoperative Treatment, 273 

Nephrectomy, postoperative treatment, 274. — Abscess of kidney, drainage 

of, 275. 

Operations upon the Bladder, 275 

General remarks, 275. — Suprapubic cystotomy, Ochsner's after-treatment 
of, 276. — Sir Frederick Treves' method of after-treatment. 279. — Steven- 
son's suprapubic drainage-tube, 280. — Temporary drainage, 281. 

LlTHOLAPAXY, 281 

Keegan's method of after-treatment, 282. — Sir Henry Thompson's method 
of after-treatment, 282. 



CONTENTS. XV 

PAGE 

Perineal Lithotomy, 283 

Postoperative treatment of, 284. — Complications following, 285. 

Perineorrhaphy, 286 

Martin's method of after-treatment, 286.— Removal of sutures, 289. — 
Kelly's method of after-treatment, 289. 

CHAPTER XIII. 

OPERATIONS UPON THE RECTUM, PROSTATE GLAND, URETHRA, 

AND SCROTUM, 293-315 

Postoperative treatment of 'hemorrhoids, 293. — Ligature method by 
Allingham, 293. — Clamp and cautery method, after-treatment advocated 
by Pennington, 294. — Secondary hemorrhage in, 296. — Abscess and fistula 
following, 297. — Stricture following, 297. 

Extirpation of the Rectum, 297 

After-treatment of, 297. — Kraske's method of treatment, 298. — Vaginal 
extirpation of rectum, Murphy's method, 298. — Postoperative complica- 
tions, 299. 

Fistula in Ano, 299 

After-treatment of, 300. — Postoperative treatment, method of ^Grant, 300. — 
Elastic ligature method, 301. 

Urethrotomy, 302 

General remarks on, 302. — Postoperative extravasation of urine after, 305. 

After-treatment in Removal of Prostate Gland : , 306 

Moynihan's method of after-treatment, 306. — Technic of suprapubic pros- 
tatectomy (E. Hurry Fenwiek), 307. — Postoperative treatment of suprapu- 
bic prostatectomy, 307. — Perineal prostatectomy, 307. — Ferguson's method, 
308. — Postoperative treatment in operation on scrotum, 310. 

Castration, 311 

Postoperative treatment, 311. — Complications following, 311. — Erasion of 
the epididymis, 312. 

Hydrocele, 314 

Circumcision, 314 

Postoperative treatment, Cheyne, 314. — Method of after-treatment ad- 
vocated by Bransford Lewis, 315. 

CHAPTER XIV. 

MISCELLANEOUS OPERATIONS, 319-350 

Ligation of Arteries and After-treatment, 319 

Abscess, 319 

General considerations of, 319. — Pulmonary abscess, 320. — Psoas abscess, 
321. — Retrorectal abscess, 321. 

Bubo, 324 

Krull's method of treatment, 324. 
Gasserian Ganglion, 325 

Excision of, drainage, and after-treatment, 325. 
Laminectomy, 328 

Closure of wound and postoperative treatment, 328. 
Spina Bifida, 329 

Postoperative treatment of, 330. 



XVI CONTENTS. 

PAGE 

Hypospadias or Ectopia Vesicle, 330 

Postoperative management of, 330. 

Symphysiotomy, < 331 

Mechanical aids in, 332. 

Varicose Veins of the Leg 2>Z2> 

Mayo's method of removal, ^Z- 

Tuberculosis of the Joints, 335 

Rest cure in, 335. — Mechanical aids in, 336. — Abscess of hip-joint, English 
method of treatment, 337. — Postoperative treatment in general, 338. — 
Phelps' method with carbolic acid, 339. — Bier's treatment, 340. — Iodo- 
form-glycerin injections in tuberculous joints, Ochsner's method, 340. — 
Whitman's method of treatment in hip abscess, 342. — Relative efficiency 
of traction and splinting in, 344. — Thomas brace, 344. 

■ 

CHAPTER XV. 

MODERN TREATMENT OF COMPOUND FRACTURES, 353-385 

Method advocated by Nicholas Senn, 353. — Drainage and counter-open- 
ings in, 355. — After-treatment in general, 356. — Antiseptic irrigation and 
continuous irrigation of wounds, 357. — Comminuted compound fracture of 
the skull, 359. — Compound fracture of the leg, 360. — Immobilization of 
fractures, 363. — Postoperative treatment of compound fractures of the arm 
at or near the elbow, 366. — Postoperative treatment of fractures of thigh, 
367. — Ambulatory treatment of fractures of thigh, 369. — Fractures in child- 
hood, 369. — Cabot's posterior splint, 370. — Complications during and after 
repair of fractures, 373. — Postoperative treatment of fracture of patella, 379. 
— Shortening following fracture of the long bones. 382. 

CHAPTER XVI. 

AMPUTATIONS, 389-410 

General remarks, 389. — Value of periosteum in 391. — Procedure for a 
normal operation, 393. — Value of typical methods, 394. — Author's dress- 
ings, 397. — After-treatment of septic cases, 399. — Postoperative complica- 
tions, 399. — Faulty stumps, 399. — Postoperative changes following ampu- 
tations, 401. — Special amputations, 402. 

Amputation at Shoulder, After-treatment, 402 

Interscapulothoracic Amputation, After-treatment, 402 

After-treatment of Amputation at Hip-joint, 403 

Amputation of the Thigh, After-treatment, 405 

Amputation of Fingers and Thumb, 406 

Amputation of Toes or Portions of Foot, 408 

CHAPTER XVII. 

EXCISIONS OR RESECTIONS OF JOINTS, 413-430 

Excision of Joints, 413 

Kocher method of excision, 413. — Essentials of after-treatment, 413. — 
Excision of shoulder-joint, 414. — Postoperative treatment of, 415. — Post- 
operative results, 416. — After-treatment of excision of elbow, 416. — Post- 
operative mechanical aids in, 417, 418. 



CONTENTS. XV11 

PAGE 

Resection of Joints, 418 

Resection of wrist-joint, 418. — Resection of hip-joint, general considera- 
tions of, 420. — Postoperative treatment of, 420. — Ambulatory splint in, 
420. — Excision of knee-joint and postoperative treatment, 423. — Cheyne's 
method of after-treatment, 424. — Excision of ankle-joint, 426. 

CHAPTER XVIII. 

OSTEOMYELITIS, OPERATIONS FOR CLUB-FOOT, OSTEOTOMY 

FOR GENU VALGUM, ETC., 433~453 

Osteomyelitis, 433 

Chronic osteomyelitis, general remarks, B. H. Nichols, 434. — After-treat- 
ment, 436. — Moorhof's method of treatment, 438. 

Club-foot, 444 

Postoperative treatment, 444. — Retention brace, 446. — Taylor's brace, 
446. — Methodical manual correction, 447. 

Talipes Calcaneus, After-treatment, 449 

Tendo-Achillis, transplantation of, 449. 
Osteotomy for Curved Tibia and Fibula, 450 

Stillman's brace in, 451. 
Osteotomy for Genu Valgum, After-treatment of, 452 

Erichsen's brace, 452. 

CHAPTER XIX. 

VALUE OF RONTGEN-RAY IN POSTOPERATIVE TREATMENT; 

MANNER OF APPLICATION, 457-467 

RONTGEN-RAY THERAPY, 45 7 

General consideration, 457. — Dosage and [method of treatment, 458. — 
Effects of treatment, 462. — Character and kind of tube, 463. — For rectal 
and vaginal treatment, 466. — Types of epithelioma curable by the Ront- 
gen-ray treatment, 466. — Manner of protecting patient, 467. 

CHAPTEK XX. 

COMPENSATIVE OR ARTIFICIAL APPLIANCES, 471-478 

Where and how to amputate, 471. — In amputation of leg, 472. — Ampu- 
tation of thigh, 473. — Amputation at the^knee, 473. — The position of the 
cicatrix, 474. — General remarks concerning, 476. — Preparation of stump 
for artificial limb, 477. — Artificial hands and arms, 477. 

CHAPTER XXI. 

POSTOPERATIVE DIETETICS, 481-487 

General rules for postoperative feeding, 481. — Diet for laparotomy pa- 
tients, 483. — After operations upon stomach, 484. — After operations upon 
intestines, 484. — After operations upon gallbladder, 485. — After opera- 
tions upon mouth, 485. — After operations upon head, 486. — Use of alco- 
hol after operations, 486. — Feeding of nutrient enemas, 486. 



Index, 489-499 



CHAPTER I. 

PREPARATION OF PATIENTS AND OF THE 
FIELD OF OPERATION. 



CHAPTER I. 
PREPARATION OF THE PATIENT. 

GENERAL REMARKS. 

The proper preparation of patients for surgical operation is of such 
importance and has such bearing upon the postoperative treatment, 
that we shall be pardoned for devoting the time and space necessary 
for a brief review of the subject. The rationale of preparatory treat- 
ment is based upon the principle that the entire system should be as 
nearly normal as is possible. Robert T. Morris says: "All the avenues 
of elimination must be open and active, in order to overcome condi- 
tions that lead to autointoxication, and render infection the more prob- 
able." 

If digestion is faulty, the diet should be restricted, and the condition 
relieved. If the liver is torpid and constipation present, laxatives are 
indicated, or brisk purgation necessary, in order that the intestinal tract 
may be rid of toxic matter. Should the kidneys be at fault, the judicious 
use of diuretics may prove of value. A general bath every third or fourth 
day, or oftener, with friction or massage, increases the action of the skin 
and relieves the kidneys. The plan of general preparation of patient 
herein advocated is that which is uniformly used at the Eldora Emer- 
gency Hospital, and applies to all except emergency cases in which 
immediate operation is imperative. 

The patient upon entering the hospital is given a warm bath, ordi- 
nary castile soap with a good flesh-brush being sufficient. If the patient 
is a female, a hot douche of one ounce of sodium bicarbonate to one 
gallon of water is given, followed by a douche containing one-half ounce 
of creolin to one gallon of water, or a one percent solution of lysol ; after 
which the patient is dressed in a clean gown and sent to a room or 
ward. A complete history of the case is obtained, and a careful physical 
examination is made to determine the nature or extent of the operation 
required and the general condition of the patient. Should this examina- 
tion reveal the existence of phthisis, Bright's disease, jaundice, diabetes 
or any other condition that would render the operation unusually haz- 



2 POSTOPERATIVE TREATMENT. 

ardous, the preparatory treatment must be directed specially to that 
condition. 

A chemic (and later, if necessary, a microscopic) examination of the 
urine is made, and the quantity of urine passed in twenty-four hours is 
carefully noted. If immediate operation is not necessary, and the 
general health of the patient is impaired, she is at once placed in bed, 
and tonics and restoratives are administered. If the appetite is lost, 
a good preparation of cod-liver oil, with tincture of nux vomica, Colombo, 
or gentian, is helpful. If the urine is scanty or deficient in quantity, 
copious and frequent drafts of water, plain or carbonated, are insisted 
upon, and are of special value if the patient is a nervous woman. Con- 
stipation is overcome by the daily administration of compound licorice 
powder, preparations of cascara sagrada, or compound aloin pills. If 
anemia is marked, fresh gelatin- coated Blaud's pills or capsules, with or 
without arsenic, have proved in our hands of greater value than many of 
the modern preparations of iron. If there is marked debility with ane- 
mia, not dependent upon hemorrhage or septic conditions, in addition to 
the above, inunctions of leaf lard (Boody) applied to the back, chest, 
and inside of the thighs, followed by massage, with daily rectal enemas 
of normal salt solution, will prove beneficial. If, however, the anemia 
and exhaustion are the result of hemorrhage, exhaustive discharges, 
or septic absorption, immediate operation is indicated, after which the 
system will be in better condition and respond more readily to tonics 
and restoratives during convalescence. 

Five or six days prior to all abdominal operations the entire intes- 
tinal tract should be gently but thoroughly evacuated. A calomel purge, 
administered in the evening and followed the next morning by a dose 
of magnesium sulfate or castor oil, is usually sufficient. 

Kelly recommends the old-fashioned black draft with carminative; 
viz.: 

Magnesium sulfate, 5 j 

Senna, 3iij 

Manna, 5 ij 

Pulverized cardamom seed, 3 j 

Boiled water, Oj. 

Boil and strain, and give 2 ounces every two hours. 

The patient is then placed upon a highly nourishing liquid diet (soups 
and broths), but no milk is allowed. On the evening of the second day 
preceding the operation a second laxative should be given, in order that 
the bowels may be free from accumulations; and during this time, in 



PREPARATION OF THE PATIENT. 3 

addition to tonics and reconstructives, we generally prescribe five-grain 
doses of beta-naphthol bismuth, preferably in capsules, with or without 
extract of cascara sagrada, as an intestinal antiseptic and laxative. 
Patients very much exhausted, or those advanced in years, who are to be 
operated upon early in the morning, may require nourishment during 
the night; beef-tea or clear soup, and, in extreme cases, brandy or whisky 
at intervals of three or four hours, may be given with advantage, up to 
two hours preceding anesthesia. The evening before the operation, 
after a light supper, another bath is given, after which the patient is 
placed in bed, and if nervous, twenty to thirty grains of sodium bromid 
is given to induce sleep. No food or broths of any kind are allowed 
during the night, but the next morning, not later than four hours prior 
to the administration of the anesthetic, a cup of hot coffee, black tea, 
or beef broth is given ; otherwise the stomach is kept empty. No purga- 
tives are administered the evening before the operation, nor do we 
permit flushing of the rectum or enemas of any kind on the morning of 
the operation, as they frequently annoy both patient and operator. 

METHODS OF PREPARATION OF PATIENT BY VARIOUS 

SURGEONS. 

For Laparotomy. — Franklin H. Martin's method is as follows: 
The intestines are emptied by mercurials and "salines. The first 
night of preparation six grains of blue mass is given. The next morn- 
ing at six o'clock seidlitz powders are given every hour until the bowels 
move, or feel as though they would move with the aid of a small enema. 
This should insure a thorough action throughout the entire length of 
the intestinal canal. If, with the above treatment, the movements are 
such as to insure a thorough evacuation and to start a free flow of bile, 
as indicated by the yellow, glistening appearance of the stool, no further 
catharsis is necessary. The lower bowel should be thoroughly evacuated, 
however, by the employment of large enemas of soap and water, repeated 
four or five times during this second day of preparation. The last 
enema should be given late in the afternoon of the second day of prep- 
aration, if the operation is to be done the following morning, or the 
next morning if the operation is to be done in the afternoon. The bowels 
are rendered less septic by large doses of bismuth and salol. During 
the first and second days of preparation ten grains of salol and twenty 
grains of bismuth subnitrate should be given every six hours. 

The bowels are stimulated by means of carminatives, alcoholic stimu- 



4 POSTOPERATIVE TREATMENT. 

lants, and strychnin. The second day of preparation oil of cloves, 
in capsules, is given. In delicate women strychnin is commenced three 
days before the operation in ^r-grain doses every eight hours, and grad- 
ually increased in quantity until ^Vgrain doses are given. The bowels 
are rendered less septic by feeding the patient on a sterilized milk diet 
for two days before the operation. 

For Laparotomy. — Ochsner's method is as follows: 

"As a rule, long-continued preparatory treatment leaves the patient 
in a much less favorable condition for a surgical procedure than a short 
and simple preparation, which serves to put the kidneys, the skin, and 
the alimentary canal in condition favorable to the elimination of the 
waste products. 

"Two or three days preceding the operation, the patient should be 
placed on a light diet consisting of sterilized food, and allowed an abun- 
dance of good water, preferably hot, in order to favor elimination through 
the kidneys. A nonirritating cathartic should be given, and, if possible, a 
warm general bath. For several years I have given, as a rule, two 
ounces of castor oil in the foam of beer or malt extract, the day before 
the operation, and a large soap-and- water enema on the morning of the 
operation. In this manner the patient is relieved in a relatively short 
time of all waste matter and is measurably removed from the likelihood 
of absorbing the products of decomposition which may be present in 
the alimentary tract. So large a dose of castor oil does not, as a rule, 
give rise to great disturbance, pain, or exhaustion. I have also found 
that the foam of beer or malt extract disguises the oil so thoroughly 
that patients who are ordinarily nauseated will bear this without annoy- 
ance. In the vast majority of patients this amount of preparation 
suffices to relieve the body of any burden it may possess which might 
interfere with the process of healing. In other words, the patient 
approaches the operation in a comparatively clean condition ; his strength 
has not been impaired by confinement, and the nervous system has not 
suffered by looking forward to the operation for a long time." 

For General Surgical Operations. — Dr. Joseph Price, of Phila- 
delphia, says: "There are two considerations to be borne in mind in 
the preparation of patients for operation. In Europe and America 
it is the rule to admit the patient to the hospital a few days before the 
operation is to be performed: (i) In the interval between admission 
and operation the patient is bathed, scrubbed, douched if the operation 
will involve in any way the vaginal tract, and is purged with calomel 



PREPARATION OF THE PATIENT. 5 

and rochelle salts. (2) The proper preparation for plastic work, in 
addition to that which is required for general surgical procedures, 
requires especial brush-scrubbing and irrigating of the mucous passages; 
and that all scar-tissue should be freed to favor easy approximation of 
the walls of fistulas. 

"In abdominal work purgation conduces to favorable postoperative 
conditions, prevents bowel distention, reverse peristalsis, persistent 
nausea and vomiting, and renders unnecessary the premature adminis- 
tration of laxatives; in short, the emptied bowel is at rest, as it should 
be, for the first twenty-four to thirty-six hours after operation. If the 
bowel is thoroughly emptied and bathed with bile, fermentation and 
consequent distention do not occur. To fortify the statement that 
thorough preparation previous to operation is necessary I may add that 
in 100 patients brought into the hospital suffering from such conditions 
as suppurative tubo-ovarian disease, diseases of the uterus rendering 
hysterectomy necessary, appendicitis, gallbladder disease, etc., and 
prepared during two days and a night previous to operation, there was 
no perceptible distention in any case, and no alarming postoperative 
complications. 

"It is an error to administer purgatives and enemas soon after opera- 
tion, or to resort to other persistent efforts to move the bowel ; this should 
have been accomplished before operation, by the use of calomel and 
rochelle salts, since these, in my opinion, give the best results. Further- 
more, calomel stimulates hepatic activity, and the presence of plenty 
of bile in the lower bowel prevents fermentation and greatly lessens the 
tendency to distention. 

"The 'let alone' treatment after operation gives the best results, but 
the free use of fluids before operation stimulates the circulation, flushes 
out the kidneys, and increases the eHmination of toxins. It is interesting 
to note that surgeons who prepare their patients after the above method, 
and withhold drink (?) for the first twenty-four hours after section, 
have the largest records for renal secretion in ounces, viz., an ounce 
or more each hour. Withholding fluids ( ?) after operations requiring 
drainage, favors the early removal of the drains. 

"The peritoneum is a huge lymph sac and it rapidly digests healthy 
and noninfectious exudates. This prevents the accumulation of such 
leakage or exudate, and hinders the development of more virulent germs. 
Leakage from perforation is primarily safe, but later germs develop in 
the form of savages, and it requires drains or gill-nets to capture them." 



6 POSTOPERATIVE TREATMENT. 

Treves' Method of Preparation. — Sir Frederick Treves' method is 
as follows: 

Period Before the Operation. — "The most thorough examina- 
tion possible of the patient should be made before an operation is 
undertaken. To carry this out, it is well that the individual should be 
under observation for some time before he appears in the operating 
room. In the case of those who have been long confined to bed, it is 
obvious that the sooner they are relieved, the better. On the other 
hand, in the matter of operations of expediency upon patients who may 
be termed healthy, it is well that they should pass through a period of 
rest before the operation is performed. Operations hurriedly under- 
taken are not unfrequently regretted. 

"In hospital practice it is better not to operate upon a man who comes 
straight to the wards from some active outdoor work, who is robust and 
has been living heartily, and who has still the vigorous throb of exercise 
in his blood and in his limbs. The practice is frequent, for the opera- 
tion has been previously arranged, and the man does not want to lose 
even a few hours' work. Such a patient is placed in an infinitely better 
condition by a few days' rest in a hospital ward. He here becomes 
accustomed to his surroundings ; he has time to be rid of the refuse matter 
in his tissues, which can no longer be cast off by muscular exertion; his 
hearty appetite is enabled to adapt itself to his present requirements; 
the excreta can be dealt with; and time is allowed (and it is needed in 
some hospital patients) to make clean the skin. To all the organs, to 
the still strongly-beating heart, and to the overworked muscles, there 
is allowed a period of repose. When the operation day arrives, the 
patient has become acclimatized, strict confinement to bed and a limited 
diet do not involve so very sudden a change, he has adjusted himself 
to his new environment, and the ordeal is met after a period of physio- 
logic rest. 

"Many small operations would do better if the patient would con- 
sent to the preliminary of a few days' rest. This is conspicuous often 
in operations upon piles, when the subject persists in absorbing him- 
self with his work up to the time of the operation. Often a business 
man will overwork himself desperately before his operation, in order 
that his affairs may not suffer in his absence. 

"What is worth doing at all is worth doing well, and not a few opera- 
tions, the performance of and recovery from which have to be com- 
pressed within a few hurried days, would better not be performed at all. 



PREPARATION OF FIELD OF OPERATION. 7 

In the case of women with long hair, the various coils and twists should 
be undone, the whole hair parted behind in the median line and dis- 
posed of in two simple lateral plaits. The hair is thus kept out of the 
way — should the operation concern the head and neck — and after the 
operation the head can rest comfortably upon the natural scalp, and 
not upon a complicated mound of wisps of hair, hairpins, and other 
foreign substances." 

Diet. — "The practice of starving a patient before an operation is 
undoubtedly unwise. The amount of the food should be suited to the 
condition of an individual who is inert and within doors. It should be 
nutritious, but small in bulk, and not of a character to leave much debris 
in the intestines. Entire abstinence from alcohol for a week or more 
before an operation might prove very judicious in not a few instances. 
The patient who 'keeps himself up' by spirits before an operation is 
preparing for himself a sore down-going after the event is over." 

The Bowels. — "The bowels should be well opened on the eve of the 
operation; and this is best effected by an aperient overnight and an 
enema in the morning." 

PREPARATION OF FIELD OF OPERATION. 

GENERAL REMARKS. 

General Preparation of the Field of Operation. — The field of 
operation requires special attention. The skin, if hairy, should be care- 
fully shaved, or preferably a depilatory should be applied ; after this the 
parts are thoroughly scrubbed with green soap and a sterile flesh-brush. 
If the integument is oily, calloused, or very dirty, gasoline, sulfuric ether, 
or turpentine may be required, but ordinarily green soap suffices. The 
parts are then washed with alcohol until all traces of the soap and 
other foreign substances have disappeared. This is followed by a i : 2000 
solution of corrosive sublimate if the skin is not broken, and, lastly, the 
parts are flushed with sterile water. The entire part or field of opera- 
tion is then covered with several layers of sterile gauze, moistened with 
a 1 14000 mercuric chlorid solution, over which a sterile bandage is applied. 
This procedure applies to amputations in general, and to all opera- 
tions on the chest, arms, limbs, hands, or feet. In operations upon the 
face, the eyebrows, beard, and mustache, if in the line of incision, should 
be carefully shaved, the scalp being thoroughly cleansed and washed 
as above directed, after which a moist antiseptic gauze dressing covering 
the entire scalp or head is applied and held in place by a bandage, which 



8 POSTOPERATIVE TREATMENT. 

is not removed until the moment of operation. In operations upon the 
head^ if not extensive, clipping of the hair to facilitate cleansing, and 
shaving the part immediately involved, will suffice. 

The Eye. — The eyebrows should be shaved, and adjacent parts, 
especially the lids and orifice of the lacrimal ducts, carefully cleansed 
with a boric acid solution, after which a pad of sterile cotton saturated 
with a solution of boric acid should be applied and held in position by 
a bandage. 

Mouth, Nose, and Throat. — In these regions antiseptics in solu- 
tion strong enough to be of value cannot be used. Miller has demon- 
strated that carbolic acid, boric acid, and potassium chlorate are of 
little value. The routine followed at the Massachusetts General Hos- 
pital is as follows: Several days before the operation the patient's teeth 
are examined by a dentist and thoroughly cleaned. Cavities are filled 
and all decayed teeth are removed. The cleaning and sterilizing are 
continued by rinsing the mouth and brushing the teeth, especially about 
the roots, several times a day, with an antiseptic solution. The pharynx, 
tonsils, and nose should be sprayed at the same time, and this treatment 
continued two or three times daily until just before the operation. 
(Warren, "Surgical Pathology.") 

The following formula has been suggested by Miller: 

Saccharin, 5ss 

Benzoic acid, gr. xlv 

Tincture of ratanhia, ". §ss 

Absolute alcohol, § iiiss 

Oil of peppermint, gtt. v 

Oil of cinnamon, gtt. iv M. 

Sig. — Dilute with ten parts water, or, better, ten parts of a 4 percent solution 
of hydrogen dioxid, and hold in the mouth for one minute, or use as a spray. 

For Stomach Operation. — W. J. Mayo's method is as follows: 
A week or ten days prior to the operation, unless contraindicated 
by exhaustion or disease, the patient is given once daily, before breakfast, 
lavage of the stomach with normal salt solution or boric acid solution, 
for the double purpose of mild disinfection, and teaching the patient to 
become accustomed to the tube. He is placed upon a nourishing liquid 
diet, exclusive of milk. Owing to the great emaciation of many of these 
patients, rectal alimentation as well as hypodermoclysis is often neces- 
sary. The night before the operation castor oil is administered, and 
if the stomach is not empty, it is carefully washed out in the morning, 
preceding the administration of the anesthetic. 



PREPARATION OF FIELD OF OPERATION. Q 

Cervix and Uterus. — The same method of cleansing or preparation 
as for vaginal operations should be done, and it is our custom in all 
operations upon the cervix, when the patient is under anesthesia, first 
to dilate and curet carefully the cavity of the uterus before proceeding 
with the operation proper. 

For Operation on Bladder, Urethra, and Kidneys. — Salol or 
urotropin should be administered in regular doses of seven and one-half 
to ten grains, three times a day, for the purpose of disinfecting the urinary 
tract. Ten grains of quinin an hour or two before the operation and 
a hypodermatic injection of one-sixth grain of morphin just before 
the anesthetic is begun will often prevent the chills and fever which 
frequently follow operations on the urethra (Bonney). The patient 
should be induced to drink large quantities of water. The morning of 
the operation the bladder and urethra require thorough cleansing 
through a double catheter by means of irrigation with boric acid or 
Thiersch's solution. This is best accomplished when the patient is 
under anesthesia. 

PREPARATION OF THE FIELD BY DIFFERENT SUR- 
GEONS. 

Howard Kelley's method is as follows ("Operative Gynecology," 
D. Appleton & Co.): 

In order that the field of operation may be rendered as nearly aseptic 
as possible before the patient is taken to the operating room, the most 
active disinfecting measures are employed. All of the articles necessary 
for cleansing the abdomen are placed in convenient reach. Usually a 
small stand is placed near the bed, and upon this are placed green soap, 
flasks of water and of mercuric chlorid solution (1:1000), a package of 
sterile towels, gauze, scrubbing mops, alcohol, and ether. The abdomen 
is w r ell exposed, the bed and clothing above and at the sides being pro- 
tected by a rubber sheet. The skin from the ensiform process to just 
above the pubes is lathered with green soap and water, and shaved well 
out from the median line. If an abdominal incision is to be made in 
any locality other than the median line, the nurse is so instructed, and 
varies the site of shaving accordingly. After shaving, the skin is thor- 
oughly scrubbed with a gauze mop. If the patient is a nervous, delicate, 
refined woman, the shaving would best be done on the operating table 
when she is unconscious. 



IO POSTOPERATIVE TREATMENT. 

The nurse now suspends the preparation while she disinfects her 
own hands, after which the skin is thoroughly rubbed and washed with 
alcohol, then ether, and finally with a i : iooo mercuric chlorid solution. 
A large sterile gauze shield is tied by conveniently placed tapes over the 
abdomen, and the patient's toilet is completed by putting on a clean 
nightgown. If she is nervous or feels weak, a wine-glass of sherry or a 
small milk-punch is given. 

The first step toward disinfection in any abdominal case, after the 
patient is put upon the table and placed under anesthesia, is the thorough 
cleansing of the vagina, by raising and separating the legs and applying 
soap and warm water vigorously, with a pledget of sterilized cotton held 
in the grasp of a pair of long dressing forceps. This step need not be 
carried out in a young woman with an intact hymen. A large funnel 
or an open speculum may be placed between the thighs close to the 
body to facilitate drainage of fluids which run down from the abdomen 
oh to the pad. The patient's clothes are drawn well above the upper 
border of the pad, her arms are flexed and folded on the chest, and 
retained in this position by the undervest being pulled up over them, 
and by tying the wrists together with a gauze bandage. The chest 
is protected by a blanket with a rubber sheet over it, and the legs are 
warmly wrapped in a blanket and sheet in like manner. If the oper- 
ation will be long, the feet should rest upon a hot-water bag, and 
another should be placed under the knees, and still others above he 
chest. For feeble patients, I use long, narrow hot- water bags encased in 
flannel, and reaching from the armpits to the knees. 

Cleansing the Abdomen. — The temporary protective gauze ban- 
dage, before referred to, is now removed by the nurse, and an assistant, 
with sterilized hands, proceeds to scrub the abdomen with sterilized 
cotton balls enveloped in gauze, applying soap and water freely for 
several minutes. Special care should be observed, both in the prelimi- 
nary preparation in the ward and upon the operating table, in cleans- 
ing the folds of the umbilicus, when it is deep, using absorbent cotton 
held in forceps. Following the soap and water, the abdomen is scrubbed 
with ether, and after this with alcohol, and finally with a mercuric 
chlorid solution (i : iooo). Before disinfecting the abdomen of unusually 
fat women, the creases formed by the overhanging cutaneous folds 
should be inspected for a slight dermatitis or eczema, which often exists. 
Unless the operation is imperatively demanded, these areas should be 
entirely healed before an incision is made through the abdomen, 



PREPARATION OF FIELD OF OPERATION. II 

as such apparently insignificant surface lesions may conceal virulent 
organisms. 

Arranging the Field of Operation. — Sterilized towels are now 
laid upon the rubber sheets on the chest and thighs and on the sides of 
the abdomen, completely covering them; a piece of sterilized gauze, 
four layers thick and i meter (i yard) square, or a sheet made for the 
purpose with a hole in the middle, is laid over the patient from breast 
to knees; finally, two sterilized towels are spread above and below over 
the ends of the cover. A -wire bracket resting on the patient's thighs 
and covered with sterilized towels serves as a convenient receptacle for 
the instruments which the operator needs to have close at hand if the 
operation is done with the patient in the horizontal posture. I provide 
for this when the pelvis is elevated by turning over the end of a towel 
stretched across the thighs, and clamping it to the sheet so as to make 
a shallow pocket, in which the instruments rest. 

Joseph Price's Method in Abdominal Preparation. — The method 
of preparing for abdominal section employed by Dr. Joseph Price, 
of Philadelphia, is as follows: 

The patient is given a hot soap-and-water bath, the skin of the body 
being thoroughly scrubbed with the bath-brush; a shampoo is given 
and the nails are manicured ; the field of operation is thoroughly scrubbed 
with soap and water; this is followed by turpentine; and this in turn 
by alcohol. A gauze towel is now wrung out of an acid solution of 
mercuric chlorid, placed over the field of operation, and left in this 
situation beneath the bandage, overnight. The site of incision is 
painted with iodin (MacDonald's method) to lessen the tendency to 
stitch-hole abscesses. 

This thorough external and internal preparation would cause many 
patients, in some countries, particularly the Orient, to leave the hospital 
in fear of the operation. And even in our own country it not infrequently 
happens that thorough purgation and rest will so relieve patients suffer- 
ing from tubo-ovarian disease that they will refuse operation, only 
to return later when the bowel is again distended and the pelvic organs 
again congested. 

In India some good surgeons avoid extensive preparation of their 
patients because of the alarm thus induced. 

Careful or severe preparation of patients favors comfortable and 
speedy convalescence, and a total absence of many of the uncomfortable 
postoperative complications, such as distention, persistent nausea and 



12 POSTOPERATIVE TREATMENT. 

vomiting, scant renal secretion, elevation of temperature, sleeplessness, and 
other conditions which are thought to indicate the employment of opium. 

Nicholas Senn's Method of Disinfection of Field of Operation or 
Injury is as follows: 

"In important operations I have relied for several years on turpentine 
in preparing the surface for the antiseptic solution. After a thorough 
cleansing with soap and water the skin is bathed with turpentine for 
a minute, when warm water and potash soap are used to remove the 
turpentine, after which the surface is ready for the efficient use of the 
antiseptic solution. Next to soap and hot water the razor is most 
important in disinfection of the surface of the skin preparatory to the 
application of the antiseptic solution. The razor not only removes 
hair, but also scrapes away the superficial layer of the epidermis, softened 
and macerated by scrubbing with hot water and potash soap. In 
operations of choice the skin may be properly prepared for a more effi- 
cient use of the razor and brush by applying to the surface to be pre- 
pared a soft-soap poultice for a few hours. This prehminary measure 
to macerate the skin is of special importance in preparing the scalp, 
scrotum, hands, and feet for operation. One of the commonest faults 
in preparing the surface for operation is that the disinfection is not carried 
far enough. For instance, in the treatment of compound fractures of 
the skull, it is not an unusual practice to limit the shaving and disinfec- 
tion to the site of the wound. In all operations on the skull the whole 
scalp should be shaved and disinfected. Women usually protest against 
such a procedure, but when informed that this is done as much for 
cosmetic as for surgical reasons, the objections are overcome. Every 
patient can expect a fair growth of hair before he recovers from the effects 
of the injury or operation. Disinfection for an amputation of the 
breast should include the whole chest and the shoulder and arm on the 
side of the breast to be removed. In abdominal operations the whole 
abdomen, including the pubic region and the chest as far as the breasts, 
must be prepared. In amputations of the leg, the leg from the seat of 
injury or disease and the thigh must be shaved and disinfected. In 
amputations of the thigh, the pelvis on the corresponding side is included 
in the preparation. In operations for hernia, the abdomen as far as the 
umbilicus, the scrotum, penis, and the groin constitute the field of 
operation requiring disinfection. 

"In operations of choice the disinfection should be made the day 
preceding, and the field of operation covered with a compress wrung 



PREPARATION OF FIELD OF OPERATION. 1 3 

out of a hot antiseptic solution, either a 2.5 percent of carbolic acid 
or a 1 : 1000 solution of mercuric chlorid; moisture and heat are retained 
by applying around the compress a ring of absorbent cotton and over 
it guttapercha tissue or waxed paper, and the whole held in place by a 
gauze bandage. The disinfection is repeated after the patient is under 
the influence of the anesthetic and before he is placed on the operating 
table. In emergency operations the disinfection is done after the patient 
has been placed under the influence of the anesthetic, to avoid delay 
and prevent one of the causes of shock. 

"Disinfection of mucous surfaces is still more difficult than of 
the skin. As a rule, complete asepsis cannot be secured by any of the 
methods in use at the present time, and in consequence of the incom- 
plete disinfection we are generally forced to abandon all attempts to 
obtain primary union of the wound throughout. Irrigation of the 
vagina or rectum with any of the more potent antiseptic solutions has 
no effect whatever on the bacteria, and besides, by doing so we incur 
the immediate risk of serious, if not fatal, intoxication by the rapid 
absorption from the mucous surfaces of the toxic agent contained in the 
solution. In the disinfection of mucous surfaces mechanical measures 
must be relied upon in preparing the parts for the operation, followed 
by the use of mild nontoxic solutions, such as Thiersch's solution or a 
saturated solution of boric acid." ("Practical Surgery," by Nicholas 
Senn, W. B. Saunders & Co.) 

Treves' Method of preparing the site of operation is as follows: 

The Preparation of the Skin. — "Care should be taken that the 
patient's body is clean. This is a surgical necessity of the utmost 
importance. A warm bath the night before the operation is desirable 
whenever possible, and a source of comfort to the patient. If time 
permits, the operation area should be repeatedly washed for some days 
before the operation. Some hours before the patient is brought to the 
theatre the skin of the operation area should be specially treated with 
a view to removing or rendering harmless the ubiquitous micrococci. 
The following is one of many plans followed: 

"1. If a hairy part, the skin should be carefully shaved. 

" 2. With soap and hot water a thorough mechanical cleansing should 
be carried out. This, however, will not destroy germs in the epidermis 
or remove fatty matter. 

"3. With ether or turpentine the skin is well rubbed, and again 
washed with soap and water. Sterilized nail-brushes should be used 



14 POSTOPERATIVE TREATMENT. 

if possible, but where the skin is tender or thin this cannot be done. 
'Rubber-sponges' are very convenient. Turpentine is more irritating 
than ether, and the latter should be used by choice. 

"4. With gauze or wool sponges soaked in an alcoholic solution or 
carbolic acid (1 in 20), or bichlorid of mercury or mercuric potassium 
iodid (1 in 500), the part is rendered really aseptic. A mixture of 1 
in 20 carbolic acid and 1 in 500 bichlorid of mercury is very efficient, 
but the solution must be made with alcohol and not with water. The 
mercuric potassium iodid solution 1 in 500 in rectified or methylated 
spirit has many advantages. It is very easily prepared, it is less toxic 
than corrosive sublimate; it does not corrode plated instruments, and 
it neither roughens nor irritates the skin. Its germicidal powers are 
equal to those of corrosive sublimate. 

"5. Moist, sterilized gauze or lint (soaked in a 1 in 60 solution of 
carbolic acid) should then be applied under waterproof tissue, bandaged 
on, and not touched until the patient is on the operating table. It is 
easy to attach undue importance to this antiseptic compress. It merely 
protects the part, and so macerates the skin that the surface epithelium 
can be rubbed off at the last moment. Aqueous solutions are practi- 
cally powerless against organisms in the epidermis. 

"6. When the compress is removed, immediately before the actual 
incision is made, it is a useful precaution to go over the area again with 
the alcoholic solution mentioned above. Finally, the skin is wiped dry 
with sterile swabs. In certain regions, such as the scrotum or eyelids, 
this cannot be done, and it may be said that it is impossible to render 
the scrotum really aseptic. The axilla is also a most difficult region 
to make surgically clean." (" Operative Surgery," Sir Frederick Treves, 
Lea Bros. & Co.) 

Keen's Method of Preparation for Cerebral Operations is as 
follows : 

It is always of the utmost importance that the head should be shaved. 
This will often reveal scars, etc., hitherto unsuspected, and no definite 
diagnosis should ever be reached or an operation determined upon 
without this procedure. The fissures, so far as is necessary, may be 
marked out on the shaven scalp by means of an anilin pencil, which is 
itself antiseptic. The day before the operation the head should be 
shaved anew, if need be, scrubbed with soap and water, next cleansed 
with ether, and then a moist bichlorid (1:2000) dressing applied. The 
dressing should be retained in place until just before the operation, 



PREPARATION OF FIELD OF OPERATION. 1 5 

when it should be removed and the disinfection repeated. Of course, 
the general preparation of the patient, as regards rest, diet, bathing, 
and the bowels, has been attended to as before any major operative 
procedure. In emergency cases, however, the entire preparation must 
usually be done under anesthesia, but here, as before, the entire scalp 
must be shaved, and the scalp cleansed, as above, with scrupulous care. 

Ochsner's Method. — "The important point in preparing a surface 
for operation lies in thorough washing with soap and water; anything 
that is done beyond this is of little importance, provided the washing 
process has been done carefully and thoroughly. In my practice the 
steps taken in preparing the field of operation are as follows: (i) 
thorough scrubbing with soft soap and w T arm water, with a moderately 
stiff brush; (2) washing the surface with a piece of aseptic gauze with 
fresh water, because the epithelial scales which have been loosened with 
the brush are easily removed in this manner; (3) soaping and shaving 
the field of operation ; (4) washing again with aseptic gauze and steril- 
ized water; (5) washing the surface with commercial, i.e., about 95 
percent alcohol; (6) washing with a solution of corrosive sublimate, 
1 : 2000. There is still a distinct superstition in favor of the use of some 
antiseptic fluid for washing the field of operation, and so long as the 
fluid employed is harmless, I believe we are justified in using it. If 
this preparation of the patient is made just before beginning the opera- 
tion, it will suffice; if made on the day before the operation, the surface 
must be protected against reinfection during the intervals. This can 
be done by applying sterile cotton or gauze to the surface, holding it 
in place by means of a carefully applied bandage. Just before the 
operation the surface is once more washed with a piece of sterile gauze 
saturated with alcohol, and is then ready for operation." ("Clinical 
Surgery," A. J. Ochsner, Cleveland Press.) 

Preparation of the Field of Operation by Means of a Germi- 
cidal Depilatory. — Robert T. Morris's method is as follows: 

Excepting on the face, Morris prepares the field of operation with 
a germicidal depilatory, and no other special preparation. This is 
applied five minutes or so before the operation. There are two depila- 
tories which are quite effective: Foral, imported from Germany, con- 
sisting of the sulfids and oxids of calcium and zinc; and sulfur starch, 
consisting of the sulfids of calcium, sodium, barium, and zinc. The 
former preparation, being a powder, is mixed with a little water and 
applied directly to the parts. After three or four minutes it is removed 



1 6 POSTOPERATIVE TREATMENT. 

by a soft piece of gauze wet with sterile water. The sulfur starch is 
all ready to apply, and for that reason it is chosen by his nurses. He 
has discarded the old or more elaborate preparation for operation. 
Both the above preparations being powerful germicides, the field of 
operation can be prepared thoroughly and rapidly after the patient is 
on the table and under ether. 

FINAL CONSIDERATIONS. 

That depilation 'is preferable to shaving, especially for women, 
admits of little argument. The author has been using the method now 
advocated by Morris for several months with such satisfaction that 
his nurses would not like to go back to the old method of shaving and 
other elaborate preparation for operation. 

The depilatory we prefer is made after the f olio wing formula : 

Crystallized sodium sulfid, 3iij 

Unslacked lime (fresh), 3x 

Pulverized starch , 3xj. 

Reduce each separately to a fine powder. Mix and keep dry in a 
well-stopped bottle. When required for use, by the addition of a 
little water a paste is formed, which is spread upon the parts about J 
inch thick, by means of a spatula or thin-bladed knife. After waiting 
four minutes the parts are flushed with sterile water, after which, in 
laparotomies, we use a solution of corrosive sublimate followed by 
alcohol. 

Solutions to be Used in the Peritoneal Cavity. — Dr. Joseph Price, 
of Philadelphia, says: " Early in the history of the surgery of infectious 
or septic or suppurative forms of peritonitis a variety of solutions — 
boracic acid, carbolic acid, mercuric chlorid, hydrogen dioxid, oxygen, 
etc. — were employed within the peritoneal cavity. Most of these have 
gone entirely out of use. Hot tap- water or distilled water gives the 
best results. Lawson Tait used hot tap-water. I employed for a 
long time distilled water, but this was found inconvenient and expensive, 
and now I am content with hot tap-water. Hot salt solution has been 
quite generally adopted, but in my opinion its employment in large 
quantities in the peritoneal cavity does not give as good results as does 
the use of boiled water. In abdominal work surgeons are now not 
doing so many complete and heroic operations as formerly. In too 
many instances they are practising puncturing, or incision and drainage, 



PREPARATION OF FIELD OF OPERATION. 1 7 

and are not removing the pathologic specimens; in short, they are not 
doing the complete and thorough abdominal surgery that they did 
a few years ago; hence the employment of salt solution gives fairly 
good results, but it is still inferior to boiled water. 

''Formerly it was the rule to free adhesions when not too far advanced 
or when freeing could be done without injury to the bowel, and to seek 
for cheesy foci and cleanse them, using iodoform and drainage. Then 
better results were obtained than in the more recent practice of aspira- 
tion, simple incision, and drainage. But in conditions requiring the 
more heroic operations, such as perforation from tuberculosis, typhoid 
ulcer, duodenal or gastric ulcer, ruptured gallbladder, or leaking hepatic 
abscess, sterilized water does the cleansing without favoring irritation 
of the bowel peritoneum and consequent adhesions. 

"Postoperative intestinal obstruction is now more common, following 
douches or irrigation with hot salt solution. The hot salt solution 
appears to be really too good — it favors arrest of infection or sepsis, but 
the irritative action causes healthy adhesions between various parts 
of the bowel. I have had to reopen three patients some days after the 
primary operation, at which time salt solution irrigation was employed 
and w T hich seemed to be the whole cause for the intestinal obstruction. 
The patients were apparently doing well when suddenly obstruction 
developed. It is interesting and pleasing to note that about all such 
reopened patients recover. I have noted recently that a few operators 
have reported having to reopen patients a second and third time, and 
yet they still favor irrigating with salt solution." 

As to Drainage. — Dr. Joseph Price says that "the confidence of the 
profession is beautifully illustrated, by multiple openings fore and aft, 
when the operator finds infectious foci, abscesses in the region of the 
gallbladder or fiver, neglected perforations, and perforative conditions; 
in short, in those situations in which mild-mannered, ecclesiastical 
surgeons have permitted the 'pathologic fluids to gravitate to a safe 
place in the peritoneal cavity.' 

"Some good surgeons employ iodoform gauze in pelvic and abdom- 
inal work. It is in puerperal lymphangitis, as a pelvic drainage or 
pack, that it should be used. Pryor, who did the best work along this 
line, got almost specific results from its employment. 

"Sterilized surgical gauze is the most valuable drain or dressing ever 
given to surgery. Some surgeons do a drain operation by using it 
throughout the operation to dry the surgical field. The same surgeons 



1 8 POSTOPERATIVE TREATMENT. 

object to drains and only employ such methods occasionally, where 
local conditions are filthy and necrotic, and where they wish to quaran- 
tine local points of infection. In sterile gauze they have just what they 
need — gauze to gill-net the germs. 

" Gauze also compensates for incomplete and imperfect methods in 
operations for resection and anastomosis, operations about the gall- 
bladder, for gastric and duodenal ulcers, and in pancreatic and hepatic 
surgery. In such situations sterile gauze cofferdams offer admirable 
protection, and they favor results which as yet cannot be attained by 
other known means. The reports of splendid work being done through- 
out the country beautifully demonstrate the correctness of the above 
statements. 

" Patients suffering from gangrenous, bad-smelling, septic conditions 
about the head of the cecum are nearly all saved by the 'open method 
of treatment.' A few years ago they were almost all lost. A few years 
ago the best surgeons in this country admitted on public stages that 
they could not save patients suffering from dirty and infectious perito- 
neal cavities. In recent discussions they have admitted that they have 
saved fifteen and sixteen consecutive cases of perforating forms of disease, 
with every known variety of germ infection. This all speaks well for 
a good-sized opening in the peritoneal cavity, a wet or dry toilet, a 
gauze pack, single or multiple drains, or no drains at all." 



CHAPTER II. 

POSTOPERATIVE WOUND SUTURE, DRAIN 
AGE, AND DRESSINGS. 



PLATE I, 



^L 



CHAPTER II. 

POSTOPERATIVE WOUND SUTURE, DRAINAGE, AND 

DRESSINGS. 

Postoperative Wound Suture. — Before closing the incision of any- 
ordinary wound all oozing points should be carefully checked, either 
by means of hot saline solution or ligature with fine catgut, and all 
hanging, ragged, or fatty tissue, liable to necrosis, should be cut away. 
If the incision is to be completely closed, the surgeon should endeavor 
to bring all the raw surfaces in exact apposition with those of the oppo- 
site side, and so arrange the deep and superficial layers of tissue as to 
avoid so-called u dead spaces" in which serum or blood may accumulate. 
For the buried sutures, catgut is preferable to any other material. Many 
surgeons make free use of silkworm-gut, silk, or even silver wire, but 
they frequently cause postoperative annoyance on account of their 
nonabsorption, and should seldom be used for this purpose. The 
double catgut ligature method, as employed by Senn for all large arteries, 
is preferable to any other method. We still prefer silk, however, as a 
ligature on the femoral or other large arteries, but in no instance has 
secondary hemorrhage occurred in any of the lesser arteries in which 
this double ligature method has been employed. In closing abdominal 
incisions the peritoneal surfaces should first be united by a continuous 
catgut suture, after which it is our custom, in order to avoid hernia, to 
insert a row of through-and-through silkworm-gut sutures, including 
the entire thickness of the abdominal wall and upturned edges of the 
peritoneum, using double-needle sutures and inserting them from 
within outward, at least J inch from the margin of the wound, and f of an 
inch apart. (See Plate II.) If, now, there are indications that tension 
will be unusually great, "stitches of relaxation," or the button sutures, 
introduced by Lord Lister, may be employed with advantage, though 
rarely required. A needle threaded with stout silver wire is inserted 
through the skin several inches from the edge of the underlined flap 
at the outer limit of the underlining, and the free edge of this is attached 
to a button. The wire is then carried across the wound under the 
tissues, and the needle brought out through the skin at the correspond- 

21 



22 POSTOPERATIVE TREATMENT. 

ing spot on the opposite side where the underlining ceases. The wire 
is then threaded to a second button, which is pushed as far down as 
possible, when firm traction is made on the wire, and the latter sutured 
in place. 

After the silkworm-gut sutures have been inserted as before des- 
cribed, but not tied, the different layers of tissue, fascia, or muscle are 
sewed separately (see Plate III) with pyoktanin catgut, and special care 
is taken to prevent these sutures being drawn too tight or inserted too 
closely together, for sometimes even slight tension will produce necrotic 
tissue, and later suppuration from pressure of ligatures alone. 

Lastly, the silkworm-gut sutures are carefully tied, and the gaping 
skin edges are closed by a continuous buttonhole or blanket suture of 
fine horsehair. (See Plate IV.) 

The silkworm-gut sutures hold all the deeper parts as well as the 
adipose tissue firmly together, while the horsehair sutures carefully 
approximate the skin edges. A small strip of iodoform gauze, one or 
two layers, is now fixed upon one side of the wound with collodion, 
and when it is dry the skin on the other side is pressed inward toward 
the line of incision, and the free end of the gauze strip is fastened with 
collodion. The incision is now ready for the external dressings. The 
closure of the skin edges of abdominal wounds or incisions by means 
of a continuous subcuticular silver wire or single strand of silkworm-gut, 
as recommended by some surgeons, is an unnecessary refinement in 
abdominal surgery. Such an attempt to unite skin wounds is more 
applicable to wounds of the face, and even here it is better surgery to 
unite the deeper tissue if necessary with fine buried catgut, and close 
the skin edges by means of sterile zinc oxid adhesive strips. By this 
means the epithelial edges are closely approximated and stitch marks 
are absolutely avoided, so that only a very delicate linear scar is left, 
which after a few months becomes quite unnoticeable. 

Irrigation of Wound During Operation. — In all aseptic operations 
irrigation of the wound or douching the wound from time to time has 
long been abandoned except by English surgeons. For the removal 
of blood-clots, to prevent oozing, or when, for any reason, irrigation of 
the wound before closing may seem required, careful sponging with 
hot normal salt solution is all that is required, and preferable to lotions 
of carbolic acid or mercuric chlorid. Ochsner's idea of keeping the 
wound as dry as possible is commendable, and should be strictly adhered 
to when possible. In operations under septic difficulties, when a cavity 



PLATE II. 




PLATE II. — Closure of Median Abdominal Incision. 
The illustration is intended to show the peritoneum closed by a continuous catgut 
suture. The deep silkworm-gut sutures are next inserted from within out, extending 
through all the tissues, including the upturned edges of the peritoneum, but'are not 
tied until the final closure of the incision. 



PLATE III. 




Plate III Shows Complete Closure of the Transversalis Fascia, Con- 
nective Tissue, and Rectus Muscles by Interrupted Buried Catgut 
Sutures. 



PLATE IV. 




4 t | 1 



Plate IV Illustrates the Flnal Closure of the Incision. 

The silkworm-gut sutures are first carefully tied, after which the skin edges are care- 
fully closed by a continuous buttonhole stitch of fine horsehair. 



POSTOPERATIVE WO I NO SI IT RE, DRAINAGE, AND DRESSINGS. 20. 

contains pus or blood, it is frequently important to irrigate thoroughly, 
but very gently, at the time of operation, with either hot normal salt 
solution, 1 : 40 to 1 : 20 carbolic acid solution, or weak sublimate solution 
of 1 :4ooo or 1 13000, if for any reason it is deemed preferable. 

Drainage. — Theoretically, a perfectly aseptic wound may be closed 
completely without drainage of any kind, and this practice may, in many 
instances, be followed by complete success. It can be accomplished 
uniformly, however, only at the expense of a large amount of time devoted 
to the permanent checking of all hemorrhage, however slight, and by 
very complete and time-consuming attention to the obliteration of all 
dead spaces. (Warren.) 

All incised tissues exude a certain amount of serum, and there are 
few wounds, no matter how carefully attended to, which are not followed 
by more or less subcutaneous blood oozing. In a small proportion of 
cases at the time of closure the wound may seem to be absolutely free 
from bleeding, but one or more vessels will, after closure, permit some 
hemorrhage into the tissues. The passing of pure serum or blood into 
the cellular spaces of a wound is certainly an invitation to bacterial 
development, which in a perfectly empty wound would not take place. 
Carefully applied drainage, in one form or other, provides against the 
accumulation of serum or accidental bleeding into the tissues and 
reduces to a minimum the chances of infection. Drainage, therefore, 
should be applied always to wounds, even in those which presumably 
are aseptic, in order to remove any possible blood exudation. In aseptic 
wounds very small pieces of gauze will answer the purpose above men- 
tioned, and may be removed within a few hours, or at the first convenient 
opportunity. This temporary drainage material should be removed, 
as a rule vfithin twenty-four hours, or not later than forty- eight hours, 
following the operation. All superficial aseptic wounds, as well as 
large and deep ones, may be perfectly drained if the surgeon introduces 
at one or two points a narrow strip of guttapercha, which should pass 
from the surface to the deepest portion of the wound that requires 
emptying. Such strips can be readily placed by means of a probe 
before closure of the wound. They should not be more than J to J 
inch in width, and should project above the surface about one inch. 
Serum will find its way out by the side of them. These strips of gutta- 
percha never leave a prolonged sinus, even when left in place for some 
time, and the wounds to which they are applied heal with great rapidity. 
(Excerpt from "International Text-book of Surgery," vol. i.) 



30 POSTOPERATIVE TREATMENT. 

Of the various forms of drainage, india-rubber tubing is usually 
the most convenient; but, instead of this, tubes may be made of absorb- 
able bone, glass, or metal. Soft-rubber tubes should always be given 
the preference when there is little liability to compression of the tube. 
When compression is liable to occur, glass is the most suitable material, 
especially in pelvic and abdominal cases. In the ordinary septic 
cases requiring drainage, in pus-cavities, etc., or in severe collapsible 
wounds, such as are formed by coils of intestines, gauze drainage, or, 
preferably, gauze rolled in rubber tissue cloth, is occasionally of great 
value especially when capillary drainage is desirable. It is used, however, 
only after septic operations, or in those which, from their nature, are 
liable to become septic. All septic wounds should be packed carefully 
in order that the gauze surface may lie in contact with every portion 
of the wound, so that all liquid may be drained off in the outer dressings. 
The external opening must invariably be wide and free. The drainage- 
tube, as a rule, may be removed after the first forty-eight hours, unless 
specially contraindicated by a continuance of the discharge. A good 
plan is to pass a stitch through the skin on each side of the tube, allowing 
it to remain untied until after the tube is removed. This will bring 
the parts in better apposition later. When positive that there will 
be little or no oozing and the wound is strictly aseptic, we frequently 
place one or two layers or small strips of iodoform gauze over, covering 
the entire length of the incision, and seal this with collodion. If a large 
cavity in the abdomen has been plugged by the use of medicated gauze 
four to six days should elapse, or even longer, before attempting its 
removal; and when the gauze is being removed, it should be wet from 
time to time with hydrogen dioxid, which renders it antiseptic and 
permits it to be more easily and less painfully removed. 

This does not apply to cases of acute necrosis of bone. When a 
bone cavity has been packed with gauze, the packing should be removed 
in twenty-four to forty- eight hours. As this is frequently very painful, 
an anesthetic may have to be employed. 

Dressings. — Essentials requisite for good wound-dressings are 
that they shall be absorbent, i.e., favor drying which interferes with 
germ-growth, and that .they shall contain germicidal substances pre- 
venting infection of the discharges, which in turn may reach the wound. 
Both of these properties render frequent dressing unnecessary, thus 
giving rest to the wound. Many kinds of antiseptic gauzes are used — 
iodoform, subiodid of bismuth, carbolated, sublimated, or borated 



POSTOPERATIVE WOUND SUTURE, DRAINAGE, AND DRESSINGS. 3 1 

gauze fulfil all indications. Kochcr, however, prefers xcroform, others 
prefer nickel, formaldehyd, mercury bicyanid, etc. "Sterilized iodo- 
form gauze 5 percent, the strength now ordinarily used, promotes drying 
of the secretions, and if sepsis occurs, will help to destroy the result- 
ant ptomains." (Dennis.) Subiodid of bismuth gauze of the strength 
of 5 to 10 percent is greatly to be preferred when there is much 
oozing of blood or serous discharge, as in some operations on the gall- 
bladder or when there is much sloughing or suppuration, as it is 
markedly astringent as well as antiseptic. Carbolized gauze of the 
strength of 2 percent, sublimate gauze of 1:2000, or plain sterilized 
gauze may be used, and should be placed loosely over the entire wound ; 
over this a layer of sterilized absorbent cotton, wool, oakum, etc., held 
snugly but comfortably in place by properly applied bandages, tends 
toward maintaining rest of the parts, promoting drainage, and relieving 
the strain upon the stitches. 



CHAPTER III. 
POSTOPERATIVE COMPLICATIONS 



CHAPTER III. 
POSTOPERATIVE COMPLICATIONS. 

Postoperative High Temperature. — Systemic reaction follows as 
a natural consequence all major operations, aseptic or otherwise. A 
few hours after the patient has recovered from the effects of the anes- 
thetic there is always more or less elevation of temperature. The exact 
cause of this transitory fever has not been fully determined. It differs 
materially from surgical fever, has no relation to infection when moder- 
ate in degree, and hence should cause little anxiety to the attending 
surgeon. This elevation of temperature is termed by Volkmann " aseptic 
wound fever;" by von Bergmann, "fermentative fever;" by Billroth, 
" resorption fever," or "after-fever;" and by more recent surgical writers, 
"simple traumatic or primary fever." The term "systemic reaction" 
seems to me more suggestive of the exact condition than any of the names 
given, however complicated the pathologic conditions accounting for 
the same. 

Symptoms. — This form of postoperative fever in aseptic cases rarely 
lasts more than forty-eight to sixty hours, and seldom exceeds 102 or 
103 F. The rise of temperature is gradual, without rigor or other 
indications of infection. The pulse usually increases in proportion with 
the rise in temperature, and when the reaction is over, the temperature 
and pulse become normal or nearly so, and thus remain throughout 
convalescence. 

Treatment. — Postoperative or reactionary fever requires very little 
treatment. One dram of the fluid extract of couch-grass in one or two 
ounces of hot water, with 15 to 20 drops of sweet spirits of niter three 
or four times a day, will tend to allay thirst and increase diuresis and 
diaphoresis. 

Postoperative Diarrhea. — Postoperative diarrhea is either the 
result of indiscretion in diet or an indication of septic infection. If due 
to the former, a laxative of castor oil followed by bismuth subgallate 
is ordinarily sufficient to overcome the trouble. If, however, the 
diarrhea is the result of septic infection, more active measures are neces- 

35 



36 POSTOPERATIVE TREATMENT. 

sary. All pus-cavities, wherever situated, must be drained, and all 
other means to overcome sepsis must be immediately resorted to. In the 
adult, 15 grains of beta-naphthol bismuth' should be administered in 
capsules every four hours, or, if a child, large doses of bismuth subnitrate 
(10 to 20 grains) with tincture of geranium are preferable. If the 
temperature is persistent and high, subcutaneous injection of anti- 
streptococcic serum is often of great value. 

Postoperative Infection. — It is not within the province of this work 
to discuss surgical bacteria, nor the form and character of the various 
infective microorganisms which create postoperative or surgical fever. 
Clinically, it is frequently difficult for even the expert to distinguish 
between the various forms of septic infection or intoxication; therefore 
it would appear impracticable to attempt to draw a sharp line between 
septicemia, pyemia, and other forms of septic infection. Neither 
theory nor practice justifies such a distinction, since the pathogenic 
organisms are the same in each of these conditions, the morbid anatomic 
changes vary more in degree than in kind, and the clinical signs do 
not enable us to distinguish unerringly between them. This inability 
to separate these forms of infection is frequently due to the fact that 
typical cases are seldom seen. The type usually found is of a mixed 
character, and often obscured by other disturbances which prevent 
one not an expert from recognizing the exact character of the systemic 
invasion. Pyemia no longer means, as its etymology implies, pus in 
the blood. By pyemia we now mean a form of blood-poisoning by 
pyogenic organisms, in which living bacteria are transported by the 
blood to distant tissues, where they multiply and produce abscesses; 
so that in pyemia the production of multiple abscesses is the typical 
pathologic phenomenon, just as in septicemia the dominant feature 
is the systemic intoxication with living bacteria in the blood. "Septi- 
copyemia" is a clinical term used to convey the impression that the 
symptoms of sepsis are as well marked as those of pyemia. (Warren- 
Gould.) 

I shall, therefore, describe under this one heading of "postoperative 
infection" the ordinary symptoms of systemic infection or blood-poison- 
ing as commonly seen and recognized by the terms septicemia, pyemia, 
and septicopyemia so far as they relate to or follow surgical operations. 

Symptoms. — The symptoms of septicemia differ in intensity with the 
extent and character of the infection. The symptoms may be very mild 
and last but a few hours ; on the other hand, if the seat of suppuration, 



POSTOPERATIVE COMPLICATIONS. 37 

from improper drainage or after supposedly aseptic operations, necrosis 
of tissue with suppuration from stitch-pressure makes its appearance 
as a result of improperly sterilized articles used during the operation, the 
symptoms may be so pronounced as to endanger the life of the patient. 
Again, if extensive surfaces capable of rapid absorption are suddenly 
flooded with infected fluids, toxemia follows rapidly, and death may 
quickly follow. For example, in operations for appendicular abscess, 
or upon a gallbladder containing pus, which is accidentally incised 
or is ruptured into the abdominal cavity, death frequently follows within 
a few hours. The ordinary symptoms of infection usually appear within 
from live to six days following operation. The sudden rise of tem- 
perature to 103 , 104 , or 105 F., preceded by a slight chill, should 
always be sufficient notice to the attending surgeon of infection and 
impending danger, and it demands prompt attention. These symptoms, 
if neglected, become more and more pronounced; the patient feels hot 
or there is a condition of alternating heat with chilly sensations. The 
skin, lips, and mouth are dry; urine becomes scanty and of a high color; 
the pulse becomes weak and rapid, and there is always more or less 
general disturbance. The patient becomes restless, the face has a 
flushed, anxious look, the temperature is always higher at night with 
morning exacerbations, sleep is troubled and unrestful, and there is 
usually delirium. The symptoms, unless relieved, assume more and 
more a typhoid condition; nausea and vomiting, with profuse diarrhea, 
extreme exhaustion, and depression of the vital force, are now prominent 
symptoms. The tongue becomes dry and brown, and even cracked; 
the breath is often foul; the perspiration from the body of the patient 
becomes sour, pungent, and of a disagreeable odor; delirium is well 
marked, and the patient passes into coma. Movements from the 
bowels and kidneys become involuntary, the temperature continues 
to rise, pulse becomes more and more rapid, and death is ushered in by 
failure of respiration. 

This slow form of septicemia may continue for several months, as 
every surgeon of experience can testify. Marasmus may increase to 
such an extent that the patient is reduced to a pitiful degree of physical 
debility, from pent-up pus. Should living pyogenic organisms, by 
means of the pus, enter the blood, and be thus carried to various parts 
of the system, we will have the condition known as pyemia, which differs 
from septicemia only in the formation of metastatic deposits. The 
typical cases of pyemia are easily distinguished clinically from septicemia 



38 POSTOPERATIVE TREATMENT. 

bv the finding of these secondary abscesses; and, in addition to the 
symptoms already described, we have marked rigors, followed by profuse 
sweating. The occurrence of these symptoms announces to the attend- 
ing surgeon that the elements of pyemia have been added to those of 
septicemia. The surgeon must ever bear in mind the important fact 
that, no matter what the character, extent, or locality of the operation, 
or whether it be five days, ten days, or two weeks following the operation, 
a sudden rise of temperature to 102° or 104 F., with or without a severe 
chill, and corresponding disturbance of the circulator}* system, always 
denotes infection and demands prompt interference. The condition 
requires the immediate adoption of drainage, or if drainage has been 
employed, it requires that it should now be more thorough. These 
signs are positive, hence delay is inexcusable. The temperature-record 
is nearly always characteristic of septicemia. The morning tempera- 
ture is lower and rises to the maximum only at night. In pyemia, 
rigors, often severe, followed usually by profuse sweating, are the out- 
ward manifestations. The nervous system is at times stimulated by 
sepsis, so that the patient does not realize his own jeopardy. (Warren, 
"Surgical Pathology.") But usually, especially after the first few 
days, the patient is restless or inclined to be in a state of stupor. 

Treatment. — In all cases of postoperative infection, septicemia, 
pyemia, etc., an attempt should be made to ascertain the source of 
infection, and all efforts directed not only toward the support of the 
patient, but the elimination of the toxins and microorganisms from the 
body. The patient's bowels must move properly, the kidneys act freely, 
and no intestinal putrefaction should be allowed to remain. It is often 
necessary to support the patient's strength from the first; hence a gener- 
ous diet should be given, and so soon as the pulse begins to fail, free 
stimulation will become necessary. All wounds should be opened, 
and after thorough irrigation with an antiseptic solution, drained freely. 
Antistreptococcic serum is often of the greatest value. A combination 
of quinin, 3 grains, with phenacetin, 5 grains, every 7 three or four hours, 
may likewise prove of utility. Should typhoid symptoms supervene, 
the treatment, as in all other exhausting diseases, should be directed to 
the support of the patient's strength by nourishing food, tonics, and 
stimulants. Antipyretics should usually be avoided, for the reason that 
they frequently act as cardiac depressants; excessive temperature should 
be overcome by cool sponge-bathing. According to Billroth, a most 
important medicinal agent to combat septic infection is alcohol. It is 



POSTOPERATIVE COMPLICATION-. 39 

borne by patients in large doses and appears to exercise a favorable 
influence upon the course of the malady. It should be administered in 
the form of brandy or whisky. In egg-nog, egg-flip, etc., we have a 
ready means of combining this agent with food. With peptonized milk 
and eggs, the alcohol may be introduced in clysters when the stomach 
fails. (Warren.) Digitalis is reserved until the pulse weakens, but 
strychnin, pushed almost if not quite to the physiologic limit, now enjoys 
a wide and apparently well-deserved popularity as a tonic stimulant. 
Feeding is just as important here as in typhoid fever, and it is the atten- 
dant's duty to see that a regular plan of feeding is arranged and adhered 
to. When the patient can no longer digest his food, it must be digested 
before it is administered. (For further information upon this subject 
the reader is referred to the chapter on "Treatment of Septic Wounds.") 

Postoperative Hemorrhage. — Postoperative hemorrhage is some- 
times a matter of great annoyance, especially after amputations or oper- 
ations upon pus-cavities, bones, ribs, the tongue, etc. The slipping 
of ligatures, faulty technic, neglect to hgate the smaller arteries or failure 
to stop all oozing at the time of operation, may, immediately following 
systemic reaction, lead to accidental or recurrent hemorrhage. This 
form of hemorrhage is manifest usually in from two to four hours 
following operations, the dressings and bandages becoming suddenly 
saturated with blood. The hemorrhage may be caused by capillary- 
oozing, or may be the direct result of constitutional idiosyncrasy or disease 
such as hemophilia, jaundice, or leukoc}themia, etc. If the bleeding 
is from an artery, however small, a large hematoma may form and 
produce distention of the woimd. In any case, all the dressings should 
be immediately removed, the source of the hemorrhage ascertained, 
and the clot, if present, removed. If the bleeding is from a vein, all 
constriction above the wound must be removed before the hemorrhage 
will cease. If the hemorrhage is not profuse, new dressings should be 
applied and pressure made by means of a snugly applied bandage. 
This will usually suffice to arrest all bleeding, especially if venous or 
capillary-. When the bleeding point is deeply seated and when it is 
not desired to open up the wound, pressure may be applied in the form 
of a compress applied directly over the surface of the wound. If this 
does not suffice to control the hemorrhage, and there is evidence of 
exhaustion, the patient must be anesthetized immediately, the wound 
laid open in its entirety, and the bleeding vessel secured. 

Bleeding from Bone. — In case of bleeding from bones, Horsley 



40 POSTOPERATIVE TREATMENT. 

has introduced an aseptic wax which can be applied by firm pressure 
over the bleeding point so as to close the opening in the bone from which 
the blood comes. The composition of this wax is: Beeswax, seven 
parts; almond oil, one part; salicylic acid, one part. When not in use, 
the wax is kept in carbolic solution, i : 20. When it is required for use, 
a small piece is pinched off, softened by rolling between the fingers, 
which of course should be aseptic, and then placed into the part of the 
bone from which the blood is. coming. The wax gives rise to no trouble 
in healing of the wound. (Cheyne.) 

Hemophilia. — Bertrand and Pilcher contend that the danger of 
capital operations is greatly overrated in this class of cases, because the 
larger vessels bleed no more than in ordinary patients. Our experience 
is limited to but two cases of congenital bleeders, and if these are a fair 
criterion, we would certainly avoid operative measures unless absolutely 
necessary; but if forced to do so, would ligate carefully the most minute 
vessels and sear the surfaces of all raw edges with the actual cautery 
and close the wound, if possible, by adhesive strips instead of using 
needles and sutures. In cases of hemophilia, suprarenal extract given 
in powdered form, 5- to 10-grain doses thrice daily, has of late been 
highly extolled. Calcium chlorid in large doses occasionally proves 
erficacious, and should be tried if other styptics fail. Weil uses a 5 
percent solution of gelatin as a local styptic in these cases with successful 
results. Wright, of Netley, introduced fibrin-ferment as a styptic for 
the purpose of checking excessive oozing from large raw surfaces. A 
piece of sterilized lint, sponge, or muslin is saturated with the ferment 
solution and laid upon the oozing surface, so as to come thoroughly 
into contact with all the bleeding points. Its action is to induce rapid 
coagulation of the blood as it issues from the vessels ; if these are small, 
the result is good. 

Secondary Hemorrhage. — Secondary hemorrhage, the dread of 
our forefathers, rarely occurs in these days of aseptic surgery. It 
occasionally occurs in amputations or major operations, however, as a 
result of the sloughing of arteries in septic wounds, especially if there 
is a condition of atheroma. The too rapid absorption of the ligatures, 
or possibly their imperfect application, may be classed as causes of this 
unfortunate occurrence. The double ligation, with catgut, of all larger 
arteries, one ligature placed about one-fourth of an inch proximal to 
the other, materially lessens the tendency to this complication. Secon- 
dary hemorrhage may occur at any time within from twenty-four 



POSTOPF.K All \ 1. COMPLICATIONS. 41 

hours to two or throe weeks after major amputations. About the 
twelfth to the fourteenth day is the time when it may be most ex- 
pected. The slightest sign of fresh hemorrhage upon the bandages 
or dressings should be regarded as important, and requiring immedi- 
ate examination. If this hemorrhage is slight, simple pressure by 
means of a bandage may suffice for its control. If, however, the 
hemorrhage is profuse, the tourniquet should be first applied, and if 
the wound be open, a ligature should be applied to the end of the ves- 
sel. In sloughing wounds or in a nearly healed stump it is often advis- 
able to ligate the vessel in continuity. (Warren.) 

In secondary hemorrhage following operations upon the tongue, 
or in cavities where it is impossible to pass a ligature, acupressure by 
means of a proper forceps, the needle of which passes through the tissues 
so as to include the vessel, may be attempted, or the wound may be 
firmly packed with aseptic gauze. These means failing, resort should 
be had to the actual cautery. 

Postoperative Hemorrhage after Nasal Operations. — Hemor- 
rhage following nasal operations is sometimes extreme and depends 
upon the character and extent of the operation. In case spurs springing 
from cartilaginous bases have been removed, simply touching the 
denuded area with a 10 percent solution of camenthol (Bishop) is 
sufficient. The same treatment will apply to many polypus operations. 
In cases of more persistent hemorrhage, such as in operations on turbin- 
ated bodies, spurs with bony bases, etc., packing the cavity is necessary. 
This packing should not be confounded with the old-fashioned ''plug- 
ging." The packing should be so introduced as to prevent hemorrhage, 
while mere plugging closes the anterior and posterior nasal openings, 
permitting the nasal cavity proper and sinuses to become filled with 
blood if the hemorrhage is sufficient. The ideal method is to pack the 
entire field of operation with some substance that will prevent or check 
all hemorrhage without causing hard coagula, one that the operator 
can adjust so as to regulate the amount of pressure, or remove part 
without disturbing the remainder. The following method has been 
used with satisfaction: A strip of gauze, one-half inch wide and in 
length one to two yards, is folded on itself, and the end formed by the 
fold is tied in the middle by a heavy silk ligature. The gauze should 
be saturated with 10 percent camenthol solution, and after pressing out 
the excessive fluid, the packing is ready for use. Apply with a slender 
forceps under good illumination, seizing the gauze at the point where the 



42 POSTOPERATIVE TREATMENT. 

ligature is attached. Pass a portion of the packing well back of the seat 
of operation, holding the ligature at each end aside and packing between. 
Fill the nasal cavity as well above the bleeding surface as possible. When 
no more can be used, clip off the excessive gauze, grasp both ends of the 
ligature in one hand, place a finger against the packing to prevent 
displacement, and make tension by drawing upon the ligatures suffi- 
ciently to obtain the pressure desired. Lastly, tie the ligature over the 
anterior or exposed end of the packing, by means of which direct pressure 
is made upon the bleeding surfaces. The packing should be allowed 
to remain forty-eight hours, after which the ligature should be clipped 
and that portion of the packing which comes away readily should be 
removed. If a small part of the packing is adherent to the wound, it 
should not be disturbed. By keeping the nasal cavity well cleansed 
with a mild antiseptic solution, the remaining gauze will loosen in 
twenty-four to thirty-six hours, and can then be removed without causing 
further hemorrhage. 

Postoperative Hematemesis. — The advent of hematemesis after 
operation is a serious complication. The mortality is high. Of twenty- 
nine cases already recorded, 69 percent died. The incidence of hemat- 
emesis is not associated with any particular form of operation. In 
the majority of instances it has followed operations relating to the abdo- 
men. But, on the other hand, Purves has been informed of two cases 
in which it followed amputation through the thigh and the removal 
of a neuroma in an amputation stump. As a rule, there is no history 
of previous gastric symptoms or vomiting of blood. Chloroform-sick- 
ness may or may not precede the hematemesis, and in only a few cases 
can be held responsible for initiating the bleeding. In those cases in 
which vomiting after the anesthetic is present, it appears more usual 
for the hematemesis to come on gradually. In the absence of chloro- 
form-sickness one finds that the first hematemesis is often quite sudden. 
In the majority of cases hematemesis sets in within forty-eight hours 
of the operation, though it may be delayed for some days. There may 
be only one or two occasions within a period of two or three hours in 
which blood is vomited, which is favorable ; or the vomiting may continue 
at frequent intervals for a period of fifteen to twenty hours. In the 
latter instance, as a rule, there will be a fatal termination within twenty- 
four hours of the onset. The vomiting is generally small in quantity, 
though in some cases one to three pints have been ejected. It consists, 
as' a rule, of blackish-brown fluid, with a varying amount of bile and 



POSTOPERATIVE COMPLICATIONS. 43 

of digested blood. The feature of these cases that is most striking is 
the state of collapse and asthenia into which the patients often enter 
so rapidly. The condition is often a perfectly obvious toxemia from 
a recognizable septic infection of the operation wound. But in many 
cases, and chiefly in those of the greatest gravity, one is at a loss to 
account with certainty for the cause of the depression and rapidly advanc- 
ing inanition. It is clear that all cases of postoperative hematemesis 
are not due to any one cause. In a certain number of cases it can be 
attributed, without a doubt, to gastric ulcer or rupture of a bloodvessel, 
when atheroma or cirrhosis of the liver is present, and in such cases it 
is no doubt precipitated by chloroform-sickness. Injury and a non- 
infected embolus from a ligated omentum may account for some cases. 
But the author believes in those cases in which such an explanation 
is not possible — and they are the majority — that the origin is of an 
infective nature. (Purves, "Edinburgh Med. Jour.") 

Prognosis. — Prognosis is always grave. The more marked the 
systemic resistance, the greater is the chance of recovery. Subdued 
or masked infection, with subnormal temperature and rapid pulse, a 
rapidly increasing vital depression, the vomiting tending to become 
regurgitant, renders prognosis graver. If bilious vomiting appears after 
one or two paroxysms of vomiting blood, the prognosis is favorable. 

Treatment. — The stomach should be washed out at once with a 2 
percent solution of sodium bicarbonate, at a temperature of no° to 120 
F., until the fluid returns clear; to be followed by a 1 : 1000 solution of 
adrenalin chlorid in normal salt solution. When collapse is marked, 
infusion of normal saline solution, with adrenalin, into a vein should be 
done as well, and both procedures should be repeated if there is any 
return of hematemesis or collapse. Strychnin hypodermatically is of 
value. All patients should be nourished by rectal alimentation, and 
no food should be given by the mouth until all symptoms have im- 
proved and the patient is in a normal condition. 

Intestinal Paresis, or Pseudo-ileus. — After abdominal section we 
sometimes encounter a peculiar condition, frequently as unexpected 
as inexplicable, which has been called by some of our modern surgeons 
"intestinal paresis, or pseudo-ileus." This implies a form of intestinal 
obstruction brought about by a certain degree of muscular paralysis 
of the intestinal tract. The term "delayed shock" has also been used 
for this affection, although the ordinary symptoms of shock are seldom 
present. The cause is usually attributed to prolonged intestinal expo- 



44 POSTOPERATIVE TREATMENT. 

sure, but in our own experience it is seldom seen after most extensive 
operations, and more frequently follows minor procedures, unattended 
by hemorrhage or intestinal adhesions. I can find no literature on the 
etiology of this subject, but the more I observe these cases, the more I 
am disposed to consider them distinctively neurotic in character, the 
abnormal nerve-force or peculiar idiosyncrasy on the part of the patient 
being responsible in a great degree for the condition of the nervous 
system which permits such profound exhaustion. The neurotic element 
may therefore enfeeble systemic resistance to such a degree as to prevent 
normal reaction. I have noticed in several instances that lumbar pain, 
or pain at the base of the occiput, preceded the local or abdominal symp- 
toms. Lastly, symptoms limited solely to the intestinal tract are rare. 
This condition of ileus is often confused with peritonitis. It differs 
from other cases of intestinal obstruction by its rapidly fatal course if 
unrelieved. 

The following is typical of the condition described as intestinal ileus 
or paresis: 

Mary S., twenty-eight years of age, brunet, medium height, slight in build, 
weight about 106 pounds, unmarried, seamstress. Had repeated attacks of 
dysmenorrhea for several years, decidedly nervous temperament, hysteric at 
times, of late quite despondent, appetite poor, urine scanty. Operation — fix- 
ation of retro verted uterus; anesthetic — ether. Patient took the anesthetic 
very slowly or tediously. Operation was simple, no adhesions or other diffi- 
culties; ovaries normal and anterior fixation was rapidly performed. Time 
of operation, twenty-six minutes. Abdominal wound closed by the ordinary 
method. No normal salt flushing. Patient recovered from the anesthesia 
with very little nausea. The following day she complained of thirst, but other- 
wise the symptoms were normal, except that the pulse was somewhat feeble. 
The conditions remained the same until the morning of the second day, but 
apparently without effect. The morning of the fourth day, about an hour 
after an ounce of castor oil had been given, she complained of severe pain in 
the back, and shortly following these symptoms the tympanitic or distended 
condition of the abdomen was first noticeable. There was also an inclination 
toward listlessness or stupor. The temperature, which had continued 
about normal, fell to about 98 (in the rectum) ; pulse became feeble and 
rapid. Attempts to establish catharsis failed, and lavage of the stomach was 
repeated several times without apparent benefit, but despite every effort the 
patient gradually passed into a comatose condition and died on the morning 
of the fifth day. At the autopsy no apparent cause for the trouble could be 
found. The abdominal wound had healed by first intention. 



POSTOPERATIVE COMPLICATIONS. 45 

Symptoms. — The characteristic symptoms of this form of ileus or 
paresis are, therefore, inability to secure bowel movement, general 
tympanitic condition of the bowels, apparent exhaustion of the vital 
forces with normal or subnormal temperature and feeble pulse — symp- 
toms usually appearing three or four days following abdominal opera- 
tions. 

Treatment. — These cases frequently terminate fatally, especially 
if not recognized early. Death is supposed to be caused by changes 
in the central nervous system, or, according to some pathologists, is 
the direct result of toxic effects due to the migration of Bacillus coli 
communis. Our aim must be to establish peristalsis as quickly as 
possible. Lavage of the stomach should be performed early, after 
which a rectal tube should be inserted to overcome the resistance of the 
sphincter ani. High rectal enemas of normal salt solution, glycerin, 
or soap and water should now be given; and if these fail to give prompt 
relief, resort must be had to purgatives, both by oral and rectal admin- 
istration. 

I rely, first, upon thorough lavage; second, upon calomel in one-fourth- 
grain to one-half-grain doses every hour, followed by a purgative of 
one dram of rochelle salts, repeated every two hours. High enemas 
of one ounce of magnesium sulfate, dissolved in three ounces of hot 
water to which one or two ounces of glycerin have been added, should 
be given every two hours until effective.* In cases in which aperient 
medicines cannot be given by the mouth, in consequence of vomiting, 
and no result has followed simple enemas, the following purgative 
enemas may be found of value: 

i. Castor oil, turpentine, i ounce of each in 10 ounces of thin gruel. 

2. The British Pharmacopoeia enema terebinthinae, containing i 
ounce of turpentine to 15 ounces of mucilage of starch. (Both of these 
preparations, however, are rather strong, and I usually employ an 
enema of one pint of gruel containing one to two drams of turpentine.) 

3. Enema of magnesium sulfate (or enema catharticum, B. P.): 
magnesium sulfate 1 ounce, olive oil 1 ounce, mucilage of starch 15 
ounces. 

4. Enema of aloes (B. P.): Aloes 40 grains, potassium carbonate 

15 grains, mucilage of starch 10 ounces. 

* Franklin H. Martin has called attention to the fact that glycerin sometimes acts 
as a violent irritant poison. He attributes two deaths to this cause when the enemas 
were retained. When these enemas are retained their expulsion should be favored 
by flushing the bowel with salt solution. 



46 POSTOPERATIVE TREATMENT. 

5. Enema of colocynth contains extract of colocynth J dram, soft 
soap 1 dram, water 1 pint. 

6. Enema of glycerin, 1 to 2 ounces with 1 ounce of tincture of asafet- 
ida and 1 ounce of magnesium sulfate, dissolved in 4 ounces of hot 
water. 

In addition to the above, a solution of pepsin with diluted muriatic 
acid, or 10- to 15-drop doses of tincture of nux vomica every four hours, 
may prove of value in restoring digestion and normal peristalsis. 

Wiggin ("Am. Med. Jour.," 1892, page 627) believes that post- 
operative intestinal paresis may be successfully overcome in almost all 
cases if the surgeon is on the watch for the early symptoms, and is prompt 
in treatment. He dwells upon the important fact that the stomach and 
bowels should be emptied before the anesthetic is given. If he has 
reason to believe that there is some tendency to paresis, and if a proper 
preparation of the stomach was not possible before the operation, he 
insists that before the patient regains consciousness the stomach shall 
be carefully washed out and four or five ounces of a saturated solution 
of magnesium sulfate be poured through the stomach-tube before it is 
withdrawn. If symptoms are first noted some hours after the opera- 
tion, the contents of the blue paper of a seidlitz powder should be 
dissolved in a full glass of water, the contents of the white paper scattered 
upon the surface, and the patient directed to drink while the effervescence 
is going on. The generation of a part of the gas in the stomach will 
help to overcome the pressure of gas in the intestines. If the draft 
is vomited, a second dose should be given, and if this is not retained, 
the stomach should be washed out and a saturated solution of magnesium 
sulfate introduced. The use of a rectal tube and of hypodermatic 
administration of strychnin and atropin is also recommended, but the 
essential part of treatment is that mentioned above. Arndt ("Zentral- 
blatt fur Gynakologie") narrates five cases of postoperative intestinal 
paresis, in all of which the patients recovered after the use of eserin. 
The preparation which the author uses is the salicylate of physostigmin, 
hypodermatically administered in the dose of -£ T of a grain. Usually 
within an hour abdominal cramps were felt, and soon after flatus was 
passed with a total disappearance of the serious symptoms — meteorism, 
shallow and rapid respirations, rapid and flickering pulse, and the appear- 
ance of collapse. 

Postoperative Lung Complications. — Postoperative bronchitis, 
bronchopneumonia, and lobar pneumonia are rare postoperative occur- 



POSTOPERATIVE COMPLICATIONS. 47 

rences, and when they occur, may usually be attributed directly to the 
anesthetic itself, or are the result of prolonged anesthesia, especially when 
the patient has been subject to changes of temperature or drafts during 
administration. Crouch, who investigated this subject at the St. 
Thomas Hospital in London, found in 2400 administrations of ether, ten 
cases of subsequent lung complications which were directly attributable 
to the anesthetic. Peterson ("Am. Med. Jour.," 1892, page 1075) re ~ 
ports two cases of postoperative pneumonia, three of pleurisy, and one of 
bronchitis. Such pneumonia may be infectious or due to inhalation of 
irritants. Bronchopneumonia is apt to follow operations on the pharynx 
or larynx, and the administration of an anesthetic in the extremes of life. 
Peterson does not agree with Prescott as to the relative infrequency of 
postoperative pneumonia. He uses the best Squibb's ether, and takes 
particular care to avoid chilling the patient during operation. In major 
abdominal operations he modifies the Trendelenburg position by 
partially elevating the head of the table after the intestines have been 
removed and held from the pelvis by packs. Metastatic pneumonia 
is more apt to occur after abdominal than other operations, especially 
when ether is employed. There is undoubtedly a hypostatic form of 
pneumonia which develops usually at the base of the lungs of a patient 
with peritonitis or other forms of sepsis. Pleurisy has often been over- 
looked on account of the pain having been ascribed to a reflex condition 
from below. 

Robb and Dettrick report (" Journal S. G. and Obs.," Vol. iii, No. i, 
page 56), after a careful analysis of 1007 abdominal operations 35 
or 3.5 percent of the patients developed inflammatory lesions of 
the pulmonary tract, from which they draw the following conclu- 
sions : 

Pulmonary complications may originate in several ways. 

1. Generally from an infection originating in several ways. 

2. From the effects of the anesthetic, (a) From the administration of 
too great a quantity of the drug, exhibited over too long a time; (b) 
from the inspiration of vomited or infective material — inspiration 
pneumonia; (c) from injurious substance contained in an adulterated 
anesthetic. 

3. Exposure, either during or after the operation, to sudden or 
excessive changes of temperature. 

4. Older patients do not show more susceptibility to lung complica- 
tion than the younger ones. 



48 POSTOPERATIVE TREATMENT. 

5. Only four of the thirty-five patients showed physical signs of 
lung involvement before operation. 

6. In three cases, acute pulmonary tuberculosis was evident immedi- 
ately after the operation. 

7. Out of the thirty-five patients, five (or 14 percent) died. In one 
case a bronchopneumonia, in a second a general peritonitis, and in a 
third an acute cardiac dilation were the immediate causes. In the 
other two cases metastatic nodules from malignant growths in the 
pelvis were found in the lungs. 

In operations upon the pleura, resection of ribs, etc., in which we 
already have extensive infection, or in paracentesis for abscess, we not 
infrequently have a postoperative extension of the infection, as manifested 
by acute inflammation of the lung and surrounding tissues. The inflam- 
mation may remain local, occasionally it extends rapidly, speedily 
producing suppuration and ending in gangrene of a portion of the lung. 

Symptoms. — The symptoms of postoperative pneumonia depend 
upon the nature or extent of the inflammation, whether simple or septic, 
and the amount of lung tissue involved. ("International Text Book of 
Surgery.") 

Simple localized traumatic inflammation usually causes but slight 
constitutional disturbance, while the physical signs will in most cases 
be obscured by other conditions, such as pneumothorax and hydrothorax. 
Spreading septic pneumonia, on the other hand, is characterized by 
grave constitutional symptoms; the temperature rises to 105 or 106 F., 
the pulse is rapid — 130 to 140 — -and there is severe local pain. The 
expectoration, which is at first bright red, soon becomes rusty colored, 
and there is marked dyspnea. On examination of the lungs, the ordinary 
signs of pneumonia may be detected, viz., dulness, increased vocal 
fremitus and vocal resonance, bronchial breathing, and crepitation; 
but not infrequently these signs are obscured by the presence of fluid 
in the pleural cavity. 

The prognosis, which, as a rule, is favorable, will depend upon the 
amount of lung tissue involved and on the presence or absence of a 
foreign body. Postoperative pneumonia shows but little tendency to 
spread — i.e., involve the other lobes — and in this it differs essentially 
from the idiopathic pneumonia. 

Treatment. — There is no routine treatment for postoperative pneu- 
monia; on the contrary, much judgment is required to decide as to the 
proper management in every case. If the disease is ushered in suddenly 



POSTOPERATIVE COMPLICATIONS. 49 

and the clinical picture presents evidences of general acute poisoning, 
accompanied by rapid rise of temperature, pain in the side, restlessness 
and dyspnea, indicating a streptococcus infection, antistreptococcic 
serum should at once be injected subcutaneously. When there is exces- 
sive congestion of the lung with great dyspnea and many coarse and 
subcrepitant rales over the lung, relief can be obtained by hypodermatic 
injection of morphin \ to h grain with 5V grain of nitroglycerin; and, 
in addition to ordinary remedies for the feeble heart, an excellent com- 
bination is 5 grains of potassium iodid, 1 minim of fluid extract of digi- 
talis, and 20 minims of fluid extract of convallaria, given every three 
hours. Hot saturated solutions of boric acid, applied on sterilized 
absorbent cotton and changed frequently, will also afford marked relief. 
As a rule, the patient should be kept quietly in bed on a fluid diet until 
the temperature has fallen to normal and the exudate has disappeared 
from the lungs. If resolution be delayed, or if bronchopneumonia 
develop, resort should be had to iron, quinin, the mineral acids, oxygen, 
cod-liver oil, etc. In elderly people or old alcoholics, in whom prostra- 
tion is out of proportion to the extent of the lung inflamed, resort should 
be had early to heart tonics, strychnin, and alcoholic stimulants. 

There is a consensus of opinion concerning indications for the treat- 
ment of postoperative pneumonia. They are: (1) To relieve the tox- 
emia; (2) to prevent failure of the heart; (3) to meet complications as 
they arise. To accomplish the first of these ends Delancey Rochester 
(Buffalo) stimulates the skin and bowels to carry off the constantly 
accumulating poisons. The bowels are kept clean and frequent liquid 
stools secured with daily doses of epsom salts, following calomel at the 
outset of the disease. Free sweating is induced by hot mustard foot- 
baths, given at frequent intervals, the patient being warmly covered 
with blankets. These baths, in connection with stimulation to maintain 
the action of the heart, are considered the most important of the thera- 
peutic measures. Xot only do they play an important eliminative part, 
but by dilating the capillaries they equalize the circulation and relieve 
the work of the heart. To maintain the work of the heart Rochester 
depends mainly upon strychnin, commenced early and given in doses 
sufficiently large. Next to strychnin he places alcohol. In case there 
is evidence of failure of the right heart, he bleeds. Locally he uses 
leeches and cups — wet and dry. 

It will be observed that the essential feature of this treatment is elimi- 
native, aimed at the toxemia — the continual flushing of the bowel and 
4 



50 POSTOPERATIVE TREATMENT. 

the diuresis induced by the mustard baths. These, as already stated, 
have a second and perhaps not less important effect in that, by dilating 
the peripheral arterioles, they dissipate the pulmonary stasis which 
endangers cardiac integrity. This treatment, therefore, has a sound 
logical basis. ("Medical Standard," June, 1901.) 

Embolism and Postoperative Thrombosis, Thrombophlebitis. — 
Postoperative thrombosis is a rare complication, most frequently occur- 
ring in anemic or elderly subjects, and usually making its appearance 
between the twelfth and sixteenth days after the operation. The clot 
or thrombus which forms in the bloodvessels is due to some interruption 
of the blood-current at a definite point. As a result of pressure or 
injury it is frequently met with after fractures of long bones. The 
ligation of a bloodvessel close to the point of entrance to the main trunk 
is also supposed to account for some cases. 

Thrombi are designated as venous or arterial, according to their 
location. The arterial is far less common than the venous. Schenick 
("New York Med. Jour.") found that out of a total of 7130 operations, 
there were 48 cases of thrombosis of the veins of the lower extremities. 
He concluded that the different complications are, therefore, more 
common after operations on the pelvis than on any part of the body, 
due to pressure upon or injury to the large venous trunk. 

Postoperative Embolism sometimes follows anesthesia as a result 
of a decomposed thrombus or the loosening of calcareous deposits in the 
cardiac valves. They may likewise follow amputations, simple and 
compound fractures. The place where the embolus lodges depends 
somewhat upon the size and place of origin. Those from the left side 
of the heart lodge in the arterial system, while those which separate 
from a thrombosis of a vein are usually carried to the pulmonary arteries. 
If the emboli obstruct one of the large branches of the pulmonary artery 
or middle cerebral artery, instant death takes place. Emboli may 
undergo the same changes as thrombi, that is, they may be absorbed, 
organized, or softened (Warren- Gould). 

The following conditions are provocative of thrombosis and of pul- 
monary embolism (Eugene Boise, "Journal S. G. and Obs.," Vol. iii, 
No. 1): 

1. Chronic exhausting diseases, with their resultant anemia and 
leukocytosis. 

2. A probable frequent increase of the calcium salts in the 
blood. 



POSTOPERATIVE COMPLICATIONS. 5 1 

3. The presence of nucleoproteids in the blood as a result both of 
the increase of leukocytes and blood-plates and of traumatism. 

4. Degeneration of the heart muscle as a result of general chronic 
anemia and of fibrous tumors, with its consequent residual blood in the 
ventricles and retardation of the blood current. 

He, therefore, suggests careful examination of the heart with reference 
to possible undue weakness. If the area of dulness is somewhat in- 
creased, if the first sound is disproportionately weak, if, after exertion, the 
pulse-rate is greatly increased, due allowance being made for existing 
anemia, and if there is a history of chronic exhausting disease, we 
may justly diagnose degeneration of the heart muscle, whether we detect 
any atheroma of the peripheral arteries or not. If, in addition to this, 
we find an excess of calcium salts, with chronic anemia, we are justified 
in taking all possible precautions against the postoperative occurrence 
of embolism. 

After operation, keep "in touch" with the heart's action. Keep 
these patients quiet, avoiding sudden movements or movements that 
will put pressure on the pelvic veins. Keep the bowels well open 
with mild laxatives to avoid straining, and use normal saline solution to 
dilute the blood and aid in eliminating calcium salts. 

The symptoms of pulmonary embolism are generally sudden in onset. 
They are dyspnea, pain, cyanosis, and rapid, often irregular, action 
of the heart. They necessarily vary according to the size of the embolus. 
Small ones cause sudden symptoms, more or less severe, which generally 
pass away with but temporary disturbance. Large ones may prove 
so rapidly fatal as to preclude all treatment. 

Treatment. — The treatment is wholly symptomatic; rest, heart 
stimulants, morphin, etc., as indicated. When pulmonary embolism 
occurs, the most promising remedy is the free administration of oxygen 
in the hope that the patient may thus be kept alive till the immediate 
shock has somewhat passed and the other branches of the pulmonary 
artery have adapted themselves to the changed conditions. 

Postoperative Thrombosis of the Mesenteric Vessels has lately re- 
ceived much attention and a number of cases have been reported. The 
clinical symptoms are so similar to those of intestinal obstructions as fre- 
quently to deceive surgeons of more than ordinary ability. A brief clinical 
picture of mesenteric venous thrombosis is described by J. Amos as fol- 
lows ("Jour. S.G. &Obs.," Vol. i, No. 4): A more or less sudden begin- 
ning or one that is slow in onset, severe colicky abdominal pain, some- 



52 POSTOPERATIVE TREATMENT. 

times localized, but often extending over the entire abdomen, often 
starting like a "stomach-ache;" also backache, diarrhea or constipation 
and vomiting; accelerated pulse, without corresponding elevation of 
temperature; abdomen only slightly distended. In some cases one 
finds strong resistance to pressure and muffled tympanites not appre- 
ciable over the abdomen. Towards the end, almost always a profuse 
bloody diarrhea, with collapse, fall in temperature, fluttering pulse, 
and death. 

He considers the question as to whether there are recognizable causal 
facts leading to a possible diagnosis of thrombosis of the superior mes- 
enteric vein, and bases his conclusions upon two cases of his own and a 
review of other published cases. In one of his cases an exact diagnosis 
was made two days before death. 

"Intestinal obstruction was considered first, but spontaneous bowel 
movements confused the diagnosis until a tumor developed in the side 
of the abdomen, which had a peculiar feel and percussion note; i. e., 
from a very hard and thick feeling tumor was elicited a strong intestinal 
resonance. Absence of a quickly arising local meteorism and the too 
large size of the tumor, spoke against diagnosis of volvulus." He empha- 
sizes particularly the peculiar combination of marked resistance and 
the tympanitic note of the tumor mass as being diagnostic. 

The only treatment is surgical where an early diagnosis is made. 

Postoperative Femoral Thrombophlebitis occurs generally between 
the second and third week of a perfectly uneventful convalescence, 
as a rule, and may follow perfectly aseptic operations upon patients 
for the most part free from septic infections at the time of the section 
or afterwards. (Abstract from article by Joseph Taber Johnson, 
"Journal Surgery and Gynecology," Vol. iii, No. i.) 

According to Bosher, of Richmond, in his report of seven cases of 
postoperative femoral thrombophlebitis 'if infection plays any part 
in the development of the lesion, this is seldom shown by other symptoms, 
for in most cases the wound heals aseptically, and the progress of the 
case prior to the appearance of the phlebitis is otherwise satisfactory." 

First, the only author who devotes any attention to this subject, 
says femoral thrombophlebitis follows about three percent of abdom- 
inal sections, that it occurs usually in the left leg. 

As to the etiology, there are two opinions held at present, which are 
directly opposed to each other. As Bosher states it, according to the 
first the lesion starts as a phlebitis due to infection at the time of the 



POSTOPERATIVE COMPLICATIONS. 53 

operation, while the second theory regards thrombosis due to traumatism 
as the primary lesion, which in turn is responsible for the inflammation 
of the vein. Those who adopt traumatism as the causative factor 
sustain their theory by reporting a series of operations in which a larger 
proportion of the perfectly aseptic cases had femoral thrombophlebitis 
than occurred in those previously infected. 

Clark makes this contention, that injury to the epigrastic veins by 
retractors, holding open the abdominal incision during protracted 
operations, is the cause of the trouble, and in proof draws attention to 
his forty-one cases, in which he insists that infection could not have 
been the cause, inasmuch as in his long series of cases septic operations 
were not as frequently followed by phlebitis as were the aseptic ones. 

While fatal pulmonary embolism occurs, as a rule, much earlier than 
femoral thrombophlebitis, they both make their appearance without 
preliminary symptoms, and practically render it impossible for us to 
pronounce a patient free from danger until at least a month has elapsed, 
from any abdominal or pelvic operation, especially in women. 

Thrombophlebitis rarely shows itself until after the end of the first 
week, and in some reported cases as late as the fourth week, and usually 
in the left leg. 

There is little to be said in regard to the diagnosis, prophylaxis, or 
treatment. Having its possible occurrence in mind after any abdominal 
or pelvic operation, we should find no difficulty in differentiating it 
from rheumatism, neuralgia, or any other complaint. 

The first symptoms are pain in the calf of the leg and in the groin, 
the leg rapidly swells, becomes milk-white in color, and pits on pressure. 

Treatment. — According to Bosher and others, the treatment of 
thrombosis is largely negative. Palpation is to be performed only when 
absolutely called for, and then with the greatest care, on account of the 
possibility of dislodging a portion of the thrombus, and thereby causing 
pulmonary embolism. "The use of massage, blisters, iodin, and all 
counterirritants is contraindicated." (Warren.) 

Complete rest in bed, elevation of the limb, enveloping the affected 
leg in cotton held in place by a lightly applied bandage, will usually 
result in complete recovery in two or three weeks without suppuration. 

Some surgeons recommend the application of mercurial and bella- 
donna ointments, unguentum Crede, ichthyol and glycerin or analgesic 
balsam, along the course of the femoral veins. 

Remedies to promote absorption of the clot and measures to prevent 



54 



POSTOPERATIVE TREATMENT. 



detachment of the thrombus are essential. Liston's modification of 
Mclntyre's splint (Fig. i) is a suitable apparatus for these leg cases. 
Hot applications of a saturated solution of boric acid, alcohol, or 
Thiersch's solution should be constantly applied to the limb and every 
effort made to promote arterial circulation of the part. 




Fig. 



-Liston's Modification of McIntyre's Splint. — (Dennis.) 



Morphin or opium should be given to relieve the pain; nutritious 
diet and alcoholic stimulants should be given when indicated. If there 
is total occlusion of the vessels and gangrene occurs, amputation is 
the only remedy. 

Postoperative Gangrene. — Postoperative gangrene from femoral 
thrombosis following operations upon the abdomen usually makes its 
appearance about the eighth to the fifteenth day, as before alluded to, 
but gangrene following amputation of crushed extremities may result 
from neglecting to amputate sufficiently high above the injured part 
to secure good circulation. Plate I illustrates this condition following 
a Teale's amputation of the leg. 

Gangrene Produced by Carbolic Acid. — Swain notes that many 
surgeons have discarded the use of carbolic acid except for the immer- 
sion of instruments which are tarnished by solutions of mercury, but 
that it is not yet sufficiently known that this too popular antiseptic is 
liable to cause gangrene when applied to the extremities even in dilute 
solutions. The dilute solutions cause no pain, and are therefore the 
most dangerous. 

Harrington has collected a total of 132 cases of gangrene from dilute 
solutions of carbolic acid. It appears from his observations that the 
damaged condition depends upon the duration of the application and 
the thickness of the patient's epidermis more than to the strength of 



POSTOPERATIVE COMPLICATIONS. 55 

the solution. Levai is quoted as saying that strong solutions are less 
dangerous because they form a more or less impervious scab. According 
to the same observer, the death of the part is due to a direct chemic 
action on all the tissues. Carbolic acid has no specific quality for 
producing gangrene, for a like effect is produced by 5 percent solutions 
of hydrochloric, nitric, sulfuric, acetic acids, and by caustic potash 
when applied to an extremity by a moistened compress for about twenty- 
four hours. Tight bandaging undoubtedly increases the tendency 
to this process, but experiments have shown that the gangrene does not 
result primarily from this cause. 

The treatment of this condition varies according to severity. If 
it appears superficial, and the case is seen soon after the removal of the 
carbolic dressing, it would be beneficial to apply a dressing saturated 
with alcohol or lime-water, but in other cases it soon becomes evident 
that amputation is the only recourse. The best prophylactic consists 
in the avoidance of the use of carbolic acid for wounds, and it is the duty 
of physicians to show by their example that the public should not make 
use of this antiseptic. 

Postoperative Cystitis. — Postoperative cystitis is usually the result 
of infection following catheterization, hence the greatest care should 
be exercised in the sterilization of the instrument and parts adjacent 
to the external meatus. The parts should be well exposed and cleansed 
before the introduction of a catheter. Despite the greatest precaution, 
however, infection sometimes occurs ; hence no patient should be cathet- 
erized until all other methods have been exhausted. 

Prevention. — The prevention of postoperative cystitis is in a great 
measure dependent on a proper appreciation of its causes. In rela- 
tion to etiology of this condition, Taussig concludes as follows. 

1. Postoperative cystitis is met with, not at all infrequently, after 
gynecological operations, particularly after the radical abdominal 
operation for cancer (60 percent). 

2. The frequency and severity of the affection is directly propor- 
tionate to the amount of bladder denudation. 

3. The two main factors in the etiology are trauma and infection; to 
these a third — urine retention — may possibly be added. 

4. Urine retention is only to a slight degree a direct factor in the 
etiology, by giving a chance for bacteria to multiply in the stagnating 
urine. For its relief, however, it requires the introduction of a catheter, 
and this is undoubtedly the most frequent cause of postoperative 



56 POSTOPERATIVE TREATMENT. 

cystitis, so that indirectly it is of the utmost importance in a consider- 
ation of the etiology. 

5. The urine retention may be due to a bend in the urethra caused by 
malposition (after Alexander's operation), or to paralysis of the detrusor 
vesicae due to interference of its blood supply, or to excision of a portion 
of its nerve supply. 

6. Trauma in these cases is usually due to ligation or bruising of 
bladder- vessels. With these is occasionally associated an incision into 
the bladder, either accidentally or, as in carcinoma or ureteral implan- 
tation, intentionally. 

7. The bacteria producing the infection may be originally in the 
bladder (previous chronic cystitis). They may have migrated from the 
rectum, the vaginal wound, along an implanted ureter, or by ascension 
from the urethra. Such modes of entry are doubtless the exception. 
The rule is, that a postoperative cystitis is primarily a catheter cystitis. 

8. Investigations show that every urethra in women confined to bed 
contains not merely staphylococci, but colon bacilli as well. The 
disinfection of the urethra is an impossibility. Hence with each catheter- 
ization germs are carried into the bladder. 

9. A few catheterizations rarely produce a cystitis. When, however, 
the number is increased, as in prolonged retention, to five or six days, 
the organ seems no longer able to resist the invasion, and a rapid multi- 
plication of bacteria with beginning of inflammation results. 

In order to prevent retention of urine, many methods have been 
suggested : 

From Baisch comes the recommendation to inject 20 c.c. of a 2 
percent boroglycerin solution into the full bladder on the evening of 
the operation. He claims that this procedure has been almost invariably 
successful in producing spontaneous urination in all cases except the 
radical operations for cancer. In the latter it failed to have any effect. 
Only rarely does the injection have to be repeated. Occasionally, 
considerable discomfort is experienced from the glycerin injections. 
In my experience they proved a greater stimulant to the detrusor than 
any of the methods previously recommended, such as faradization, 
massage, hot applications, or strychnin injections. Several times, 
however, the effect seemed only to be temporary, and after one or two 
spontaneous urinations, retention again set in. Baisch's success, 
however, certainly warrants giving this plan a fair trial before aban- 
doning it. It should be added, that in every case the instructions of 



POSTOPERATIVE COMPLICATIONS. 57 

Baisch to catheterize if urine was not voided in thirty minutes was 
carried out. 

Irrigation of the bladder with protargol solution was tried by Wer- 
theim extensively, commencing the day after operation, but did not 
yield the expected results. On the other hand, Baisch found that by 
irrigating the bladder after each catheterization with one pint or more 
of 3 percent boric acid, postoperative cystitis only rarely developed, 
even after the extensive cancer operations. He has recently given a 
detailed report of his results. Out of thirty-one patients on whom a 
radical abdominal operation for cancerous uterus had been performed, 
only one was able to urinate spontaneously on the evening of the opera- 
tion. Five died. The remaining twenty-five were subjected to bladder 
irrigation following operation, sometimes for as long as eighteen days. 
Only three of them developed a cystitis, and in but one case was it a 
severe infection. Sampson failed to get results even with this method, 
for in four out of five cases in which he tried it, cystitis arose. I believe 
Baisch does well to emphasize the importance of carrying on such irri- 
gation until there is no longer any residual urine; for in many cases a 
spontaneous urination may occur without the bladder being completely 
emptied. 

The chief points in the prophylaxis w r ould, therefore, be: 
i. Try to avoid urine retention by the use of one or several of the 
following methods: Filling the bladder with sterile water at the con- 
clusion of the operation, injecting boroglycerin solution into the full 
bladder, having the patients sit up out of bed as early as the nature 
of the operation will allow 7 . 

2. In the operation, handle the bladder carefully and cover its denuded 
surface as well as possible before the close. 

3. Prevent the introduction of germs from the urethra as far as 
possible, by using a double catheter such as devised by Rosenstein. 

4. Internally, you may give urotropin, helmitol, etc. 

5. Above all, wherever catheterization has to be continued for some 
time, irrigate the bladder each time with one to two pints of boric acid 
solution and continue such irrigations with each catheterization, not 
merely until the first spontaneous urination, but until there is no longer 
any residual urine. 

Treatment. — The first and most important consideration in the 
treatment of cystitis is to discover the cause of the morbid condition. 
Albuminuria or nephritis the immediate effects of sulfuric ether, lesions 



58 POSTOPERATIVE TREATMENT. 

of the spinal cord, and constitutional conditions such as gout and 
lithiasis must not be overlooked. 

Local treatment of cystitis consists in the use of irrigations or injec- 
tions with antiseptic solutions. For this purpose a large variety of drugs 
is available, including silver nitrate, the newer silver salts, potassium 
permanganate, boric acid, fluid extract of hydrastis, etc. Irrigation by 
means of a double catheter should be employed and repeated two or 
three times a day. One of the best means of flushing the bladder and 
diminishing the irritating effect of the urine is to let the patient drink 
abundantly of pure hot water. If mineral waters are preferred, they 
should not be carbonated, as this sometimes acts as an irritant. Intern- 
ally, the balsams, such as copaiba, cubebs, and sandal- wood, are much 
less frequently prescribed than formerly, and this applies as well to such 
remedies as buchu, triticum repens, corn- silk, uva ursi, etc. At the 
present time urotropin enjoys the greatest popularity, its action depend- 
ing upon the liberation of formaldehyd in the urine, which is thereby 
prevented from undergoing decomposition, while the pathogenic organ- 
isms are either destroyed or inhibited in their growth. The value of 
urotropin has been fully established by numerous observations, but 
more recently attention has been called to the fact that in some cases 
its use is not devoid of injurious consequences; thus, it may give rise 
to gastric disturbances, diarrhea, hematuria, and strangury. These 
by-effects may be obviated by giving the drug well diluted, and by 
reducing the dose in cases in which the urine is very acid, or by giving 
it in alternate doses with a saturated solution of sodium phosphate. 
Urotropin sometimes fails to act in cases of ammoniacal fermentation, 
in which case the urine should be rendered slightly acid or the bladder 
irrigated frequently, and kept as nearly empty as is possible. 

For the treatment of more severe cases of cystitis the reader is referred 
to articles upon this subject as discussed in text-books. 

Postoperative Neurasthenia. — Postoperative neurasthenia is becom- 
ing quite common, and is certainly the most annoying and intractable 
of all postoperative neuropsychoses. It is now an established fact 
that the injury and shock of surgical operations may be followed by 
symptoms of well-recognized neuroses or psychoses, or the symptoms 
of one or more of these disorders may be blended in the same case. 
Many of these are mixtures of hysteria and neurasthenia ; others may be 
shown to depend upon the structural changes in the central nervous 
system of which the clinical manifestations are associated with symptoms 



POSTOPERATIVE COMPLICATIONS. 59 

of hysteria and neurasthenia. In postoperative neurasthenia the mental 
state is subject to wide variations. The disorders assume the type of 
hypochondriasis less frequently than melancholia or dementia. 

Hysteria or neurasthenia following surgical operations is not always 
of the pure type seen when the affection develops in men or women from 
nontraumatic causes, and whether it is due to the trauma, directly 
attributable to the operation, the result of fright, or, lastly, the effects 
of the anesthetic used, has as yet to be determined. By far the larger 
number of cases of postoperative hysteria or neurasthenia may be ex- 
plained on the assumption that the symptoms are those of hysteria or 
neurasthenia, functional disorders of which the pathology is unknown, 
the symptoms, as a rule, differing in no essentials fiom those of organic 
nervous disease. When the factors are active in the production of post- 
operative neurasthenic symptoms, an important place is occupied by 
previous disposition, either hereditary or acquired through excesses. 
In hysteria and neurasthenia originating from causes other than trauma 
it often may be discovered that previous to the appearance of symptoms 
the resisting powers of the nervous system had become enfeebled through 
various causes. Unfortunately, however, postoperative neurasthenia 
frequently appears in persons previously healthy and active, and it is 
often impossible to discover any predisposition thereto. The influence 
of "suggestion" by sympathizing friends is frequently an important 
factor in the causation of both postoperative neurasthenia and hysteria. 
In many cases it seems as though these disorders or their appearance 
are in a great degree due to the fact that the sufferers have been told 
by sympathizing friends of the terrible ordeal through which they have 
passed. Examples of the bad effect of such statements are numerous. 
The following is a typical case of this character: 

Mrs. A. B., aged thirty-four, a very stout and apparently rugged woman of 
German descent, was the wife of a well-to-do farmer, but had always been 
accustomed to doing heavy indoor and outdoor work; had borne no children. 
During the summer of 1900 she complained of occasional abdominal pains 
and menstruation became somewhat profuse. Upon examination later it was 
discovered that she was afflicted with a fibroma of the uterus. In March, 
1 901, myomectomy was performed. The recovery from the operation was 
rapid and no ill results were apparent. A few months after the operation 
there supervened a condition of extreme nervousness, irritability, sleepless- 
ness, and despondency. She finally settled upon the conviction that the op- 
eration had not been performed in a skilful manner. Her physical condition 



60 POSTOPERATIVE TREATMENT. 

was perfect, menstruation normal and regular, appetite very good, bowels 
regular, pulse- rate and temperature normal, and no evidence of organic dis- 
ease. The skin over the whole body was hypersensitive. The patient finally 
became bedfast. So persistent was she that something was wrong within 
the abdominal cavity that an exploratory laparotomy was performed with the 
hope of at least effecting a mental cure. This operation was performed in 
June, 1 90 1. Nothing whatever abnormal was discovered, no adhesions were 
found, patient recovered from the operation and returned to her home greatly 
improved, and was able to do her own housework. Later, however, she 
gradually passed into her former condition. In August, 1002, about fourteen 
months after the last operation, she was bedfast. An examination failed to 
find any evidence of organic or nerve injury, there was no contraction of 
visual field, no paralysis, no disturbance of the functions of the bowels, blad- 
der, or ovaries. The patient was depressed, tremulous, and anxious, skin 
was hypersensitive, pressure over the vertebras caused expressions of pain. 
She complained of gaseous distention after eating, and persisted in her re- 
fusal to sit up or walk. Evidently a confirmed neurasthenic. 

Neurasthenia arises, according to some authors, from a general defect 
in the nutrition and action of the nervous system, or the result of reflex 
irritation or degenerative changes in the nerves. It may follow surgical 
shock or exhaustion of the nervous system. In my experience the 
severity, character, or extent of the operation has no special determining 
influence. Functional neuroses often follow minor surgical traumat- 
isms. 

Symptoms. — The general characteristics of neurasthenia are so 
familiar as not to require repetition here. Patients complain of exhaus- 
tion, mental irritability, loss of memory, disturbed sleep, headache, 
palpitation of the heart, dyspeptic trouble, foul breath, constipation, 
nausea, etc. (Thorburn.) All symptoms tend toward chronicity; 
many are sensitive or emotional and subject to migratory or neuralgic 
pains in the abdomen, limbs, or head. There is very frequently no 
impairment of general nutrition. The absence of organic lesions or 
disease, and of distinct symptoms denoting the existence of pathologic 
changes, simplifies the diagnosis. While it is true that many of these 
cases are complicated by the hope of legal redress, yet they frequently 
occur independent of ''suggestion" or the counsel of friends or lawyers. 
The symptoms are often complicated by exaggerated or purely imagin- 
ary troubles; and the reflexes are usually abnormal. 

Nature, Duration, and Severity of Case. — No very important 
conclusions can be drawn from the nature of the case — that is, whether 



POSTOPERATIVE COMPLICATIONS. 6 1 

it is of a hysteric or neurasthenic character — as regards the prognosis. 
(Warren.) The duration of symptoms is indefinite, owing to the 
tendency to the formation of "associated" neuroses. Many of these 
patients become chronic hypochondriacs, yet because of the fact that the 
symptoms as a whole are often the result of delusion, efforts should 
be made to relieve their pitiable condition, and the patient should have 
the benefit of thorough expert treatment. The features that make the 
prospect of recovery unfavorable are neurotic temperament, lack of 
firmness or a natural tendency to nervous depression, and loss of will- 
power, energy, or desire for recovery. Many assume a form of lethargy 
or morbid inaction, from which nothing arouses them, and they remain 
thus for years. True neurasthenia is an obstinate and tedious affection; 
the hysteric form is less serious. 

Diagnosis. — "The physician, in approaching a case assumed to be 
one of the posttraumatic neuroses, is obliged to consider, first, whether 
the patient is simulating or is really ill; next, the type of the illness, if it 
exists; and, further, to what extent it may be considered as superficial 
and under the domination of excitement and the events of the operation, 
or, on the other hand, due wholly or in part to actual lesions of the 
nervous system or to profound disorders of circulation and nutrition. 
It is his duty to determine how far it may be attributed to the action of 
previously existing neuropathic tendencies, or contributive degeneracies 
of other origin, or to other causes not connected with the operation." 
(Warren and Gould, "International System of Surgery.") As regards 
the commoner types of disease (hysteria, neurasthenia, the psychoses, 
the spinal scleroses, the cerebral and spinal degenerations of vascular 
origin, strain of the lumbar muscles, spondylitis secondary to injury 
of the vertebras, etc.), while the diagnosis in well-marked cases is easy, 
there are certain essential considerations to be borne in mind. The 
chief of these, according to Bailey, are the following: It is important 
to distinguish between true neurasthenia and hysteric neurasthenia, the 
former being a more severe affection than the latter. The psychoses 
may, on the same principle, have a hysteroid element in them, the spinal 
scleroses and subacute myelitis may be simulated by hysteria or hyster- 
oid affection, though a judicial consideration of the whole case will 
generally make the diagnosis possible. Finally, it is important to note 
that hysteria may coexist with organic affections, so that the physician 
must be prepared to diagnose both conditions separately. 

Treatment. — Enforced rest, as suggested by S. Weir Mitchell, 



62 POSTOPERATIVE TREATMENT. 

absolute isolation from friends and relatives, cauterization of the back 
of the neck, as recommended by Shoemaker, correction of the digestive 
functions, chalybeates and tonics as required, and, lastly, static elec- 
tricity, complete the list of methods of treatment suggested by the best 
authorities for the relief of this condition. 

Postoperative Insanity. — Postoperative insanity, like other post- 
operative neuroses, bears .no definite relation to the character or extent 
of the operation performed, and is of itself a comparatively rare occur- 
rence. The majority of the cases reported can be attributed to the 
effects of the anesthetic and most frequently occur among patients 
predisposed to attacks of insanity; or they may be due to acute sepsis 
or metastatic cerebral abscess resulting from operation, in which case 
we have a rise of temperature and other acute symptoms denoting infec- 
tion. These cases, although presenting symptoms of acute mania, 
should not be classed as postoperative insanity. The true type of 
postoperative insanity may be justly attributed to morbid brooding, 
fright, or mental anxiety over the operation, or from the previously 
diseased condition calling for operative interference, and not to the 
operation per se. Operations upon neurotic individuals or persons of 
high-strung nervous temperament are frequently followed by hysteria 
or neurasthenia, as heretofore described. Picque and Brand ("Med. 
Bulletin") have published an important paper upon mental disturbances 
or psychoses following surgical operations. Under the term "post- 
operative psychoses" they include only delusions with or without mental 
confusion, and affecting the intellectual functions only. Neurasthenia, 
hysteria, or hypochondriac characters or other neuroses are not included 
in the category of postoperative psychoses. All forms of cerebral 
excitement or delirium which persist after the operation, and which 
may be attributed to an undue sensitiveness of the patient to the anes- 
thetic, are stigmatized as "toxic pseudodelirium," which is of transient 
character, lasting, as a rule, but a few days. True postoperative psy- 
choses are serious forms of mental disturbance which require care and 
treatment in an institution. 

Symptoms. — The symptoms of postoperative insanity are variable. 
They comprise maniacal excitement, delusions of persecution, and 
melancholic depression, accompanied frequently with suicidal tendencies. 

Treatment. — When there is the slightest indication of insanity, 
the patient should always be under the charge of a constant attendant. 
Rest, careful attention to general nutrition and hygiene, isolation from 



POSTOPERATIVE COMPLICATIONS. 63 

friends, with judicious employment of nerve tonics, valerian, and hyoscy- 
amus, with hypnotics and general tonics as indicated. 

Postoperative Delirium frequently results from prolonged fasting 
and exhaustion of the nerve centers incident thereto. This is often 
noticeable after operations upon the stomach and intestinal tract, 
in which, from long-continued suffering and fluid diet, the patient 
finally loses his mental equipoise, and symptoms of mania or melancholia 
agitans supervene with little or no warning. 

The personal experience of the author warrants him in emphasizing 
the statement that it not infrequently happens in these enfeebled patients 
that the long- continued use of iodoform, powder or gauze drainage, 
increases the tendency to delirium, or may possibly be the exciting cause 
thereof. An examination of the urine should therefore be made, and 
if iodin is found, other forms of antiseptic or aseptic dressings should 
be substituted. 

The prognosis in this form of delirium is usually favorable, but the 
period of convalescence may be greatly protracted. 

Postoperative Jaundice.— R. DeBovis reports two cases of jaundice 
following surgical and obstetric operations. The first was in a young 
man upon whom he operated for a small inguinal hernia. Chloroform 
was used as an anesthetic and the operation lasted about half an hour. 
Healing occurred by first intention. On the second day jaundice 
appeared, which by the third day had increased in intensity. The urine 
was characteristic of this condition. The temperature and pulse were 
normal. Toward the sixth day the jaundice began to disappear rapidly. 
The second case was that of a woman in whom there was rigidity of 
the os uteri during labor, due to thickening and cicatrization from 
previous labors. In order to facilitate delivery, the tissues were incised 
under anesthesia. Three days later jaundice appeared, and was 
accompanied by a slight elevation of temperature. It diminished 
gradually, and when she was discharged, twelve days later, it had 
entirely disappeared. Similar cases have been reported by various 
writers. DeBovis believes that, aside from jaundice due to operations 
upon the gallducts, which is of grave prognosis, there is a form of jaundice 
following operations which is benign in character and of short duration, 
due to simple biliary retention by reflex action. The author has seen 
several cases of postoperative jaundice occurring from the third to the 
sixth day. The attacks are usually of a mild type and subside without 
special medical treatment in from eight to ten days. 



64 POSTOPERATIVE TREATMENT. 

Mayo Robson has recently drawn attention to the value of calcium 
chlorid in the treatment of patients suffering from jaundice at the time 
of operation. He administers the drug by the rectum in doses of 60 
grains, thrice daily, until all signs of oozing from the wound have ceased. 
It is better, however, to use this drug as a prophylactic agent, beginning 
administration two or three days prior to operation. It is claimed 
that if administered for longer than three or four days, in large doses r 
it actually diminishes the coagulability of the blood. Ruspini's styptic 
(Liquor ferri perchloridi with an equal part of tincture of matico) is 
recommended by English writers, and is best applied by soaking narrow 
pieces of lint and then carefully packing the wound and applying pres- 
sure over it. 

Postoperative Erysipelas. —This is a form of infection characterized 
by an acute inflammation of the skin and deeper structures, accompanied 
with fever and general constitutional disturbance. The affected area 
is usually well defined, the skin assuming a red or crimson color, or 
may appear of a slightly purple color and shine or glisten from edema 
of the parts. The skin becomes hot and tender to the touch and blebs 
or vesicles later make their appearance. The affection is due to the 
introduction of Streptococcus erysipelatis. The cocci may enter 
directly through the wound and from this point spread rapidly through 
the lymphatics or capillaries to the surrounding tissues, or if the patient 
happens to be afflicted with a local form of erysipelas at the time of the 
operation, the operative wound, though at a distance, may later become 
infected by the cocci being carried through the circulatory system. 

The following case seems to warrant the belief that the virus may be 
transmitted through the circulation: 

G. S., aged thirty-one, farm-hand, was suffering from an acute attack of 
facial erysipelas to which he was frequently subject. In going to his home 
in an adjacent county he unfortunately had his right foot crushed in attempt- 
ing to board a moving freight train, necessitating the amputation of the toes 
and a part of the foot. Every precaution possible was taken at the time of the 
operation to prevent infection of the operative wound, but on the fifth day 
erysipelas of a phlegmonous character developed in the wound, requiring 
numerous incisions and constant irrigation. The patient was confined to his 
bed several weeks, but ultimately made a good recovery. 

As to whether or not erysipelas is communicable or contagious is 
still a much argued question; the majority of surgeons favor the idea 
and the abundance of clinical proof offered appears to warrant the 



POSTOPERATIVE COMPLICATIONS. 65 

belief that the disease is, at least in some of its forms, communicable. 
In these days of aseptic surgery it may be possible for a patient with 
erysipelas to remain in a surgical ward without contaminating others, 
but there are cases of such virulence, especially of the phlegmonous 
type, which should, in my opinion, be promptly isolated and the strictest 
measures taken to prevent possible contagion. I believe isolation to be 
the safest and most rational course to pursue, even in the mildest of 
cases, and I would be unwilling to permit a patient afflicted with any 
form of erysipelas to enter my surgical ward. 

Symptoms. — The disease may appear any time during the healing 
of the wound, but usually commences from four to seven days following 
the operation. There are, as a rule, certain premonitory symptoms 
preceding the actual attack, such as malaise, headache, loss of appetite, 
and a feeling of tension and pain about the wound. In other cases the 
disease may begin suddenly with a severe rigor, without any premonitory 
symptoms. However the attack may be ushered in, it is followed by a 
rapid rise in temperature to about 104 F. Along with the rise in 
temperature there is headache, probably nausea and vomiting, a rapid, 
soft pulse, foul tongue, great thirst, scanty urine, diminution of the 
discharge from the wound, and swelling of the neighboring lymphatic 
glands, to which latter there may be red lines running from the wound. 
Occasionally there is acute delirium. In from ten to twenty-four hours 
after the rigor a red or crimson blush, sharply marked off from the 
surrounding parts, appears around the wound, and the reddened portion 
is somewhat swollen. The redness increases and usually spreads along 
the course of the lymphatic vessels, that is to say, toward the trunk. 
The margin of the inflammation can be felt as a distinctly elevated 
ridge. Where the tissues are lax, as in the eyelids or the scrotum, the 
swelling may be very great, and bullas may form upon the surface. 
Bullas may also appear, although not so frequently, when the trunk 
or limbs are affected. During the course of the disease there is often 
albuminuria. After six or eight days there is generally a rapid fall 
of the temperature, which has remained high during the acute period. 
The constitutional symptoms disappear, the appetite improves, the 
redness gradually fades and usually disappears by the middle of the 
second week; finally, desquamation occurs. This desquamation is of 
great importance because it is in the scales of epidermis that the chief 
source of the erysipelas infection is to be found. In severe cases the 
disease may end fatally, during the second week, from pyrexia and 
5 



66 POSTOPERATIVE TREATMENT. 

general exhaustion. The most serious form of erysipelas is described 
as phlegmonous or gangrenous. In such cases, along with the symp- 
toms already described, there is suppuration into the subcutaneous 
tissues, which sometimes takes the form of an abscess, but more com- 
monly manifests itself by a diffuse cellulitis ; occasionally the skin sloughs 
together with the deeper tissues. In these cases the patient usually 
soon passes into a typhoid state and death frequently occurs. 

Treatment. — The treatment of erysipelas is both constitutional and 
local. The internal treatment should be supportive; antipyretics 
and purgatives and other depleting remedies should be avoided, since 
the system requires strength to combat the sepsis. Mild and argeeable 
tonics with proper nourishment are usually all that is necessary. The 
much extolled remedy, tincture of the chlorid of iron, as recommended 
by Hamilton Bell and other English writers, has proved of very little 
value except in chronic cases, and has now been abandoned by many 
surgeons. In case the infection is pronounced and the temperature 
rises to 103 , 104 , or 105 F., antistreptococcic serum frequently proves 
of marked benefit, and should always be used in severe cases. In the 
aged and feeble or in those broken down by wasting diseases alcoholic 
stimulants are of value if used judiciously. To control delirium the 
bromids, chloral, or hyoscin may be employed with safety, and, lastly, 
a mild aperient, such as effervescent sodium sulfate in dram doses, 
should be given as required. 

Local Treatment. — Lotions and ointments innumerable have been 
recommended. In the rapidly spreading forms of erysipelas strenuous 
efforts should be made to check the progress of the disease. The old 
method of drawing a line on the skin around and above the area of 
redness, with silver nitrate, or painting the skin in a similar manner 
with iodin or creasote, may still be used with good results if employed 
early. 

Kraske's method of making numerous small scarifications in the 
skin around and above the seat of infection acts on the same principle, 
but likewise must be employed early if benefit is to be expected. Later, 
injections of a 2 percent solution of carbolic acid, as recommended 
by F. P. Henry, although at times painful, often yield excellent results. 
The injections should not be made into, but a little beyond, the border 
of the inflamed parts. The needle of the syringe should be pushed in 
various directions under the epidermis in order to disseminate the fluid 
as extensively as possible. Injections may be repeated once daily and 



POSTOPERATIVE COMPLICATIONS. 67 

gradually increased to twice or three times a day, using about one fluid- 
dram of the solution at each insertion. Solutions of salicylic acid, 5 
to 10 percent, and sodium sulfocarbolate, 20 percent, have also been 
used subcutaneously with advantage. 

Topical Applications. — Of the numerous topical applications 
recommended, a solution of creolin, one-half to one dram in a pint of 
sterile water, appears to have proved the most beneficial. It is non- 
toxic and may be applied over large surfaces. Lint kept constantly 
moist with the old-fashioned lead and opium wash is frequently very 
soothing and tends to allay the itching and burning of the inflamed 
wound or skin. Later, when desquamation is noticed, ointments or 
oleates act better. Ichthyol ointment, 10 percent eucalyptol ointment, 
zinc oxid ointment, castor oil, or plain cosmolin will not only tend to 
allay irritation, but lessen the chance of dissemination of the infective 
desquamating epithelium. 

Treatment of the Phlegmonous Types. — The graver forms of 
phlegmonous or gangrenous erysipelas, or malignant edema, must be 
dealt with promptly and heroically by long and deep incisions. Many 
lives have been saved by the prompt interference of the surgeon. Warren 
states that free incisions allow the escape of the pent-up discharges, and 
free drainage prevents the invasion of bacteria and their products into 
the lymphatic system, hence free drainage is the prime factor in the 
successful treatment of these cases, after which constant irrigation 
should be carried out in the manner described under the treatment of 
septic wounds. 

Postoperative Peritonitis. — The treatment of postoperative peri- 
tonitis varies greatly; the cause of this variance being possibly the vast 
difference in the type and severity of the infection. A small localized 
collection of pus in the abdominal cavity often becomes safely walled 
off in a few hours, while, on the other hand, the infection of the central 
portion of the abdominal cavity is inevitably fatal unless prompt surgical 
interference is adopted. 

Before entering upon the subject of operative treatment, which is 
called for in a large majority of the cases, it may be well to indicate the 
scope and limits of purely medical means. If the diagnosis has been 
made early and the condition is mild or localized, divided doses of 
calomel, followed by a brisk saline purge, may serve to remove some of 
the fermenting contents of the bowels and assist in the removal of the 
toxins from the peritoneal cavity. But it must always be borne in 



68 POSTOPERATIVE TREATMENT. 

mind that the formation of adhesions or the possibility of perforations 
is an absolute contraindication to the use of any laxative, so that the use 
of such treatment has come to be limited to postoperative cases. Local 
measures — application of cloths saturated with alcohol, applied as hot 
as possible, poultices, stupes, ice-coils, and the like — serve chiefly to 
make the patient more comfortable, and probably influence very little 
the actual course of the disease. (" International Text-book of Sur- 
gery.") 

Believing that the presence of fluid in the peritoneal cavity favors 
extension of the disease, and that the pelvic peritoneum, from its lessened 
capacity for absorption, is better able to combat infection, Fowler 
(Brooklyn) ("New York Medical Record") has treated patients by 
elevating the head of the bed in order to facilitate the passage of septic 
fluids from the general peritoneal cavity to that of the pelvis, where they 
would do less harm and be more readily removed by drainage methods. 
He insists that the elevation of the head of the bed shall exceed the foot 
by at least 12 to 15 inches. A large pillow is placed beneath the knees 
and the buttocks are allowed to rest against this to prevent the body 
sliding down. The pillow is made fast by a bandage to the sides of the 
bed. A number of patients were treated by this method with satis- 
factory results. 

Should operative measures be decided upon, shock is to be avoided 
by the use of an anesthetic, and ether is perhaps the best for its stimulant 
effect upon cardiac muscle already weakened by the action of the ab- 
sorbed toxins. To aid the general anesthesia and to diminish the 
amount of ether necessary to prevent any movement on the part of the 
patient — for that is all that is required — a moderate preliminary dose 
of morphin hypodermatically is valuable. Its effects are also desirable 
after the operation in quieting the patient and diminishing peristalsis, 
and it in no way interferes with subsequent treatment by means of laxa- 
tives. In extreme cases it is best to employ cocain, or cocain com- 
bined with morphin, for purposes of anesthesia, because any general 
anesthetic would inevitably be fatal. A very thorough cleansing op- 
eration is almost impossible under cocain, yet enough can be done by 
abundant irrigation and subsequent drainage to give the patient his 
best chance for life. 

One procedure which should never be omitted previous to operation 
upon patients in whom there has been fecal vomiting, or even a tendency 
to intestinal paresis and gaseous distention, is a thorough lavage of 



POSTOPERATIVE COMPLICATIONS. 69 

the stomach. This simple procedure obviates many of the dangers of 
a general anesthetic. There can be no infection of the air-passages, 
with subsequent septic pneumonia, because the patient does not regur- 
gitate the foul contents of his stomach and upper bowel. There is 
less likelihood, also, of persistent vomiting after the operation, and 
the patient gains a period of relief and quiet. 

The choice of an incision depends largely upon the condition one 
expects to find. If the infection follows an appendicectomy or the 
breaking of an abscess into the peritoneal cavity, and if the symptoms 
do not point to a general invasion of the whole peritoneum, the opening 
should be made with a view to giving the best possible exposure of the 
field to which the trouble may be confined. On the other hand, if the 
patient's condition shows that the infection has become a generalized 
one, the incision should be made in the median line, and long enough 
to give free access to all parts of the abdominal cavity. There are 
then two methods of procedure : (i) Careful mopping up of all exudate 
from the cavity and the loops of the gut, and (2) free irrigation with 
hot normal salt solution. The choice depends on the condition found. 
If the process is spreading, but does not as yet involve the whole of the 
peritoneum, it is improper to irrigate and thus spread the infection to 
tissues still intact. The rarity of a universal peritonitis is seldom appre- 
ciated. What usually passes for this condition is a fairly well localized 
inflammation without any limiting adhesions. In such conditions it 
is wiser carefully to sponge out all the visible exudate with pads of sterile 
gauze which have been wrung out of hot normal salt solution. A 
certain amount of traumatic injury is necessarily inflicted and this is far 
more easily cared for by nature than the additional toxemia which 
would inevitably follow irrigation. This cleansing process should never 
extend beyond the visible hrnits of the disease; the remainder of the 
abdominal cavity is to be protected carefully by large, dry, sterilized 
gauze pads passed between the intestines and the abdominal wall, 
to he left until all the cleansing process is over. The removal of these 
pads from the abdomen is much facilitated by having a long tape firmly 
stitched to one corner; this also relieves the operator from the embarrass- 
ment and doubt of having left a pad in the abdomen. When the infec- 
tion is undoubtedly general, the patient's life should not be risked by 
any prolonged search for the site of the perforation, but an ample 
median incision is to be made, and the whole peritoneal cavity thoroughly 
flushed with salt solution of a temperature of at least 105 F., or even 



70 POSTOPERATIVE TREATMENT. 

higher, for it is well to remember that the temperature of the blood 
in these patients is often over 107 F., and to obtain any stimulant 
effect from the heat the solution should be several degrees higher. A 
temperature of the salt solution as hot as the hand can comfortably 
bear represents from 107 to no° F. When the water returns clear 
from all portions of the abdomen, it has accomplished all that is possible ; 
but none of the dependent portions of the peritoneal cavity must be 
forgotten. Special attention should be paid to the pelvis, the supra- 
hepatic spaces and those outside the colon. A long tube should be 
carefully passed to each of these spaces to obtain the full cleansing 
effect of the stream. All easily loosened masses of fibrin and pus should 
be gently sponged off the surfaces of the viscera, and so much as possible 
of the fluid still in the abdomen should be absorbed by gauze pads. 
It is well to make two counteropenings, one in either flank, through 
which drainage can be made, and any accumulations in the depressions 
outside the colon thus removed. The choice of the drainage material 
lies between gauze and rubber tubes. Most operators at the present 
time incline to the use of gauze; some prefer to combine the two, using 
gauze wicks about the tube, but retaining the latter because of the 
ease by which the discharges can be removed by occasional irrigations 
without disturbing the dressings to any extent. In any case the material 
used must be capable of carrying off large quantities of fluid for the 
first forty-eight hours, as the absorptive power of the peritoneum is 
so reduced by inflammation and the traumatism of the sponging and 
irrigation that it is utterly incapable of taking care of the fluid secreted. 
Recently the suggestion has been made to remove the intestines 
from the abdominal cavity and forcibly scrub them with gauze pads 
wrung out of hot salt solution. During the process a continuous stream 
of the same fluid is to be kept flowing over the exposed loops, to prevent 
chilling and to wash away the loosened masses of fibrin and pus. Such 
a method is certainly not applicable in case of great septic absorption, 
and in which the diminished strength of the patient often could not 
survive the anesthetic. Its field, if any, is more in those cases of fairly 
well-localized peritonitis of a low grade of virulence and a tendency to 
produce large quantities of fibrin without much general toxemia, and 
even in these it is unnecessary, and, therefore, to be condemned. Another 
method, which has as yet been little used, is a continuous bath. This 
plan of placing the patient in a bath of sterilized salt solution at 98 F. 
after opening the abdominal cavity, is indeed a heroic measure, but the 



POSTOPERATIVE COMPLICATIONS. 7 1 

results of its use in cases of suppurating joints and other severe infection 
would certainly warrant its trial in desperate conditions. It permits 
the free escape of pus lying between the coils of the intestines, and with 
the least traumatism. Experimentally it has been found that the peri- 
toneum of animals would perfectly well endure an exposure of two hours 
in a warm normal salt bath without serious change in the lining endo- 
thelium. In man, however, no very remarkable results have been 
reported, probably because it has only been tried on moribund patients. 

The suture of the incisions is rarely advisable; it takes time and 
prolongs the anesthesia. The sides of the wound can be easily held 
together by the dressings. In cases in which the distention of the 
intestines is so great that difficulty is experienced in returning them to the 
abdominal cavity, it is an excellent plan to puncture several of the 
most distended loops after their removal from the proximity of the 
incision, and thus permit the escape of gaseous and fluid contents. A 
quick and perfect method of accomplishing this is by making a purse- 
string suture of three stitches at the point selected, between which a 
good-sized aspirator-needle pierces the bowel, relieving gas and liquid 
contents without contaminating the neighboring parts. Before closing 
the puncture excellent results have been obtained by injecting into the 
lumen of the gut several ounces of saturated solution of epsom salts. 
This promotes peristalsis, cannot be vomited, and thus carries off the 
poisonous contents of the bowels. An enema of eight ounces of hot, 
black coffee with an ounce of whisky should follow the operation. 

The above measures are recommended and adopted by many of the 
very best surgeons, and constitute an epitome of their latest writings 
upon the subject. The plan, however, suggested by E. W. Dwight 
•"Medical and Surgical Reports, Boston City Hospital"), can be 
accomplished in much less time and has proved, in the few cases in 
which we have employed it, to be equally effective, and preferable 
to the more formidable measures. The method is as follows: An 
incision is made as directly over the source of infection as possible — 
a one-and-one-half to two-inch incision is sufficient for this purpose. 
If the purulent fluid is found free in the abdominal cavity, no attempt 
is made to discover its source. Through the incision a large glass 
tube, one inch in diameter and twelve inches long, is introduced. 
Through this is poured a large quantity of normal salt solution as 
hot as can be borne with comfort on the back of the hand. Flushing 
is kept up until the fluid returns from all portions of the peritoneal cav- 



72 



POSTOPERATIVE TREATMENT. 



ity quite clear. The tube is then removed, the excess of fluid permitted 
to escape, and three or four gauze drains are placed in different direc- 
tions in the abdomen. A very large quantity of salt solution is used 




Fig. 2. — Two Way Abdominal Irrigator. 

Illustrating the method of connecting it and holding it so as to control both inflow and 

outflow. Devised by Blake and employed at the Roosevelt hospital for 

flushing and cleansing the peritoneal cavity. 



— 20 to 25 two-quart bottles in a single operation. If this method is 
carried out accurately, it is believed that the toxic dose is reduced to the 
minimum with the least traumatism to the peritoneum. 

J. B. Murphy, of Chicago, has recently called attention to the value 



POSTOPERATIVE COMPLICATIONS. 73 

of introducing large quantities of water into the rectum by means of 
a constant though slow and gentle flow. The patient is placed in 
Fowler's position and a nozzle, perforated in three or four places and 
attached to a container by rubber tubing, is inserted into the bowel 
through the anus. The container is placed but a few inches above the 
level of the rectum, so that the fluid shall flow in very slowly, no faster 
than it is absorbed. The flow may be regulated by compressing the 
tube, so that no fluid shall accumulate in the bowel. From a pint to a 
quart will ordinarily be absorbed in an hour. 

The multiple openings in the nozzle permit the escape of flatus very 
readily. 

It is stated that the absorption of large quantities of fluid during the 
first hours after the operation reverses the lymph-current in the peritoneal 
lymphatics, as a result of w T hich they pour out fluid upon the peritoneum 
instead of absorbing it therefrom. Furthermore, the heart and kidneys 
are stimulated and the amount of urine voided is greatly increased. 

Neither food nor drink is given by the mouth, but if deemed advisable 
highly concentrated liquid food may be mixed with the water put into 
the bowel. 

At the time of operation the cause of the peritonitis is removed or 
remedied, all delaying minutiae of technic disregarded, and tube-drain- 
age instituted at the lowest part of the pelvis through a suprapubic 
incision, as well as through the original operative wound. 

The value of this treatment has been attested by the experience of a 
number of other surgeons, notably Le Conte, DaCosta, and Bonney, 
of Philadelphia. 

The after-treatment must be sharply stimulating; strychnin hypo- 
dermatically, in doses of -^ to ¥ V grain, can often be given every two 
hours with great advantage; a little morphin may be given advanta- 
geously if required for pain or restlessness. The great advantage of 
the morphin is that it allows the patient to breathe with more freedom, 
because of the fact that such movement no longer causes pain, and thus 
permits the free motion of the diaphragm. This is known to be one of 
the most potent factors, physiologically, in promoting the flow of lymph, 
and hence in absorbing fluids from the peritoneal cavity. An ice-coil 
to the abdominal wall is often exceedingly grateful to the patient, and 
no doubt relieves to a certain extent the congestion and inflammation 
of the diseased peritoneum. Nourishment is advised within twelve 
hours in amounts as large as the patient can bear. If vomiting con- 



74 POSTOPERATIVE TREATMENT. 

tinues, rectal feeding is substituted. Should small localized abscesses 
subsequently develop in different parts of the peritoneal cavity, anes- 
thesia should then be induced and the abscess cavities emptied. 

Summary. — There are certain matters in connection with the treat- 
ment of postoperative peritonitis which must be constantly borne in 
mind. There are relative indications. There are complications that 
demand intervention. There are conditions where, in the author's 
judgment, an operation offers the only chance, and where the patient 
will surely die unless saved by surgical procedures. Death may occur 
in any event. It must occur under certain conditions unless prompt 
relief is afforded. 

The first matter of importance in this connection is that the bowels 
must act regularly — that is, that they should be open. With severe 
abdominal pain, nausea and vomiting, excessive tympanites, the inges- 
tion of but a small quantity of nourishment, which is often exhibited 
in concentrated form, it is not reasonable to suppose that there shall be 
a free fecal discharge every day, but at the same time any indication 
of obstruction must occasion serious anxiety. With the bowels inflamed 
we should understand just what may happen. The tympanites and 
tenderness may prevent our recognizing a volvulus, an intussusception 
or an obstruction caused by adhesions. The surgeon must not wait for 
stercoraceous vomiting: he must be prepared to act so soon as there is 
evidence of obstruction. 

To assert just what symptoms wall warrant an operation is a very 
difficult matter. If the treatment of peritoneal infection begins by 
giving salines, calomel, enemas of glycerin and water, or concentrated 
solutions of magnesium sulfate, we usually succeed in evacuating the 
bowels. If we fail, it may be necessary to flush the colon. If these 
measures are unavailing and if there is nausea and vomiting, an explor- 
atory incision is indicated, especially if there is excessive tympanites 
which prevents the palpation of any abdominal tumor that might be 
caused by some form of obstruction or adhesion. The possibilities 
of a spontaneous recovery when peritonitis exists are problematic in 
the extreme. Excessive tympanites is seldom per se an indication for 
surgical interference. It persists after all other symptoms have subsided, 
sometimes causing much inconvenience. 

As a matter of fact, the whole subject of operative relief for peritonitis 
may be summed up in very few words. If pus is present, it must be 
evacuated ; if adhesions cause obstruction, or if conditions prevail that 



POSTOPERATIVE COMPLICATIONS. 75 

make it probable that their formation, or the formation of pus, will 
jeopardize the patient's life, we must operate, and it is well to do so 
without delay. Other conditions admit of a difference of opinion, 
and the existing circumstances will determine our plan of action. The 
conditions I have mentioned admit of no controversy. Consistent and 
courageous surgical aid is the only thing to be thought of. 

Postoperative Bedsores. — Bedsores, a form of gangrene, are the 
result of continued pressure, and it is very important to remember this 
when the patient has to be kept in one position for a long time. Under 
such circumstances, the parts subjected to pressure are very apt to die, 
and this is more especially the case with soft parts over long promi- 
nences, such as the sacrum, or those subjected to pressure against the 
edge of a splint. The gangrene in these cases is moist. 

The treatment of bedsores resolves itself into: (a) prophylaxis, 
(b) treatment when a bedsore is threatened, and (c) when it is actually 
present. 

(a) Prophylaxis. — The essential points in the prophylactic treat- 
ment are, in the first place, to avoid continuous pressure, or so to vary 
or diffuse it that it shall not exert itself too long or too injuriously on 
one part; and, in the second place, to keep the skin dry. The first 
indication is carried out by frequently altering the position of the patient 
or the part, or by so arranging matters that the pressure shall not be 
brought to bear on a bony prominence. For instance, the patient may 
lie on a ring-pillow, the opening in the pillow being opposite the part 
where pressure is to be avoided. Or he may lie upon a soft wool pelt, 
tanned with wool intact. 

Another and in most cases the best plan is to place the patient on a 
water-pillow or water-bed, so that the pressure does not remain localized 
to any one point, but is distributed over a wide area. In using a water- 
pillow care must be taken that the proper quantity of water is intro- 
duced; if too much is present, the pillow becomes hard and convex, 
and does not adjust itself equably to the skin. On the other hand, 
if there is too little water, the patient is not properly supported, and the 
part comes in contact with the bed. Just sufficient water should be put 
in to keep the patient floating, and a good method of testing this is to 
bear one's whole weight on the pillow by pressing the two spread-out 
hands in the center; if they just touch the other side of the water-pillow, 
the patient's body will float when laid upon it. The water in the pillow 
should be tepid when introduced and it ought to be changed every three 



76 POSTOPERATIVE TREATMENT. 

or four days, otherwise it is apt to become foul. A large water-pillow 
must, of course, be filled upon the bed. The pillow is covered by a 
draw-sheet, and great care should be taken that this is quite smooth. 

A second point in avoiding bedsores is to see that the parts most 
exposed to pressure are kept dry. The patient should be turned over 
twice a day, and the sacrum, or any other region subjected to pressure, 
should be carefully washed and thoroughly dried; and not only dried, 
but rubbed gently with a soft towel so as to improve the circulation and 
nutrition of the tissues. It is then dusted over with powdered boric 
acid or talcum powder. 

(jb) When a bedsore is threatening, that is, when the skin is becoming 
red, the same measures should be continued, but it is well to relieve the 
pressure entirely by placing a ring-pillow around the part on the surface 
of the water-bed. In addition to gently rubbing the part with a soft 
towel, the circulation should be further promoted and the epidermis 
hardened by the application of some stimulating fluid, such as spirits 
of wine or whisky. The spirits of wine is allowed to dry on the skin, 
which is then rubbed, and subsequently dusted with powdered boric 
acid. At a later period, when the skin is becoming raw, lint spread 
with equal parts of balsam of Peru and resin ointment is a very good 
application. It should be renewed night and morning, after the part 
has been washed, dried, and rubbed with alcohol. 

(c) When a bedsore has formed, the slough, and subsequently the 
sore, must be kept as nearly aseptic as possible. If the patient is lying 
on the part, it is impossible to carry out one of the chief principles in the 
treatment of gangrene, viz., to favor the drying of the slough; and that 
being so, there is no objection to the use of antiseptic ointments, which 
is, after all, one of the most valuable methods of keeping the affected 
area aseptic. The best is the full-strength boric or eucalyptus oint- 
ment, changed, when the slough has separated, for the quarter-strength 
boric. Balsam of Peru, either alone or mixed with white of egg in equal 
proportions, is also a good dressing. So soon as possible the patient 
should be made to lie on the side, when the sore will usually begin to 
heal. Meanwhile the general nutrition of the patient should be attended 
to by the administration of light and easily digested food and stimulants. 



CHAPTER IV. 

GENERAL PRINCIPLES OF AFTER-TREAT- 
MENT AND POSTANESTHETIC 
COMPLICATIONS. 



CHAPTER IV. 

GENERAL PRINCIPLES OF AFTER-TREATMENT AND POST- 
ANESTHETIC COMPLICATIONS. 



GENERAL REMARKS. 

It would be impossible to formulate a definite set of rules to cover 
the postoperative management in major and minor operations. Much 
necessarily is left to the judgment of the attending surgeon and 
nurse. Some patients are very susceptible to pain; others bear pain 
surprisingly well. Many are extremely restless, nervous, or hysterical; 
others calm, stoical, and indifferent. Again, some patients are pleasant, 
considerate, and easily cared for; others exacting, irritable, and very 
difficult to control. Tact and gentleness as well as firmness are required 
for the proper management of these various temperaments, and it should 
always be borne in mind that patients are entitled to every possible 
comfort or assistance, so long as it does not interfere with, their recovery'. 

Immediately after major operations, and in minor cases in which 
there is evidence of shock or exhaustion, and before the patient is removed 
from the operating table, a high rectal enema of normal salt solution at 
a temperature of no° F. should be given, and, if necessary, a hypoder- 
matic injection of strychnin, -£§ to -^ grain, should be administered 
and the patient carefully and gently placed in bed. The patient should 
then be surrounded with warm-water bottles. But the danger of burns 
from too close contact with hot- water bottles has not been exaggerated ; 
they should never be placed next the patient, but wrapped in flannel 
cloths or placed outside of the blankets. The patient must never be 
left alone. A reliable nurse or attendant should remain with him to 
guard against accidents from vomiting or choking or prevent any act of 
violence on his part if delirious, and especially to note any evidence of 
sudden collapse which may call for immediate measures of relief. It 
is also important that the anesthetist should remain with the patient 
until he has recovered from the immediate effects of the anesthetic. 

It is our custom, unless specially contraindicated, to place the patient 

79 



80 POSTOPERATIVE TREATMENT. 

upon the right side (Fig. 5). This position is also strongly recommended 
by Hewitt in the following language: * ; In this position stertor at once 
ceases; the tongue gravitates to the sides of the mouth, and a free air- 
way is established; mucus and saliva are not swallowed; coughing is pre- 
vented., and should vomiting occur, any vomited matter will readily find 
an escape without interfering with breathing.*' 

Xo nourishment whatever should be given by the mouth for a few 
hours following anesthesia. To relieve extreme thirst, the frequent 
sipping of hot water or tea is often very grateful to the patient, and may 
assist in causing free emesis, which sometimes tends to relieve the feeling 
of nausea; when this does not suffice to allay the thirst, the holding in 
the mouth of a cloth or a gauze sponge dipped in cold water and changed 
frequently may afford great relief. 

Pallor and feebleness of pulse which follow anesthesia are usually 
associated with nausea and vomiting. They may, however, indicate 
approaching shock, the result of prolonged anesthesia or cardiac failure. 
The head must be kept low and the patient warm, and quiet, free respi- 
ration maintained; enemas of brandy or turpentine with hot water 
should be given, and, in critical cases, artificial respiration is re- 
quired, with the hypodermic use of sulfuric ether, 10 to 30 minims, 
strychnin, -^ grain, digitalin, -^ grain, and brandy, or, lastly, adrenalin 
solution. In one instance where there was great cardiac depression, 
the result of chloroform narcosis, prompt and complete recovery resulted 
from the use of adrenalin chlorid (1:1000) in 1 ounce of warm normal 
salt solution administered hypodermatically. 

POSTOPERATIVE POSTURE OE THE PATIENT. 

General Considerations. — Much has of late been written upon 
the important subject of posture or position of the patient immediately 
following operations. Res:, bodily and mentally, is the first considera- 
tion. The patient, being placed in a bed previously warmed, should 
be rendered as comfortable as possible. It seems to be a custom or 
fancy, among American surgeons especially, that after all operations 
of severity the patients must be placed in the dorsal or recumbent posi- 
tion, in which uncomfortable posture they are forced to remain, not 
being allowed to move or turn upon either side for several days. 

Allingham, of England, and Fowler, of Xew York, appear to have 
been the first to abolish this ancient custom. Very few people indeed 



POSTOPERATIVE POSTURE OF THE PATIENT. 



8l 



sleep wholly upon the hack, and when forced to do so, arc exceedingly 
uncomfortable. There are many rational objections to this position. 
Women who are kept long in this posture after laparotomy are very 
liable to develop cystitis from inability to empty the bladder completely. 
It has been our custom for many years to place patients upon the right 
side so soon as placed in bed and before they recover from anesthesia. 
This posture (see Fig. 5) tends to prevent mucus or saliva from collecting 
in the mouth and fauces, and thus decreases the tendency to nausea 
and vomiting. Later, if proper abdominal bandages have been applied, 
we allow the patient, with the assistance of the nurse, gently to assume 
whatever position is most comfortable. Owing to the prominence of 
the sacrum and spinal vertebras, the dorsal position, if long continued, 
is especially apt to cause bedsores, which is not the least objectionable 
feature. The tendency also to meteorism or gaseous distention of the 
abdomen is increased by the dorsal position. 




Fig. 3. — Prone Position as Recommended by Allingham. 



Prone Position. — Allingham, of England, has pointed out the value 
of this position after extensive injury to the extremities or larger arteries. 
Under such circumstances the integrity of the limb depends upon the 
rapid development of collateral circulation. When it is desired to drain 
a wound opening upon the anterior surface of the body, in abscess of 
the appendix, suprapubic cystotomy, etc., the prone position is far 
more desirable and the patient finds it more comfortable than the 
dorsal position. 

Fowler's Semi-erect Position (Fig. 4). — This position, so ably rec- 
ommended by Fowler, is applicable especially to cases of appendicular 
6 



82 



POSTOPERATIVE TREATMENT. 



abscess, operations upon the stomach or thorax, septic peritonitis, and 
laparotomies in general, particularly when the patient has been exposed 
to abdominal infection. In this position all fluids within the abdominal 
cavity gravitate to the lowest portion, thus limiting the area of possible 




Fig. 4. — Fowler's Semi-erect Position. 

infection and increasing the resisting powers of the peritoneum. This 
position is far more comfortable than the dorsal posture, and admits 
of greater freedom in breathing, use of the arms, etc. 




Fig. 5. — Right Lateral Position. 

The Lateral Position (Fig. 5). — The patient lies upon the side, 
the knees flexed, with a small pillow or pad between them, and a pillow 
to support the back. This position is considered by many to be the 
most comfortable possible. The muscles of the abdomen are relaxed, 
relieving all tension upon the wound or stitches. Patients in this posi- 
tion urinate more readily and require less attention. Old people and 



POSTOPERATIVE NAUSEA AM) VOMITING. 83 

children should be allowed greater freedom after operation, and if the 
dressings are hxed with broad adhesive straps, no unnecessary restraints 
need be insisted upon, except, possibly, enforced quietude. 

POSTOPERATIVE NAUSEA AND VOMITING. 

General Considerations. — The condition of the stomach prior to 
anesthesia, the kind of anesthetic employed, duration of administration, 
character or extent of operation, as well as temperament of the patient, 
all have their influence upon postoperative nausea and vomiting. If 
the patient has not been properly prepared, and there is solid or liquid 
food remaining in the stomach, vomiting will usually be troublesome. 
Thorough lavage is the best means by which it may be alienated. As 
regards chloroform, sulfuric ether, and A. C. E., and other mixtures, 
authorities agree that the administration of ether is more often followed 
by transient retchings, but severe, protracted, and dangerous vomiting 
is more common after chloroform. "Vomiting after A. C. E. mixture 
is usually slight, though sometimes protracted. Old people are rarely 
affected by after-sickness from A. C. E., even though the administration 
has been prolonged. Billroth' s mixture of chloroform and ether has 
been received with great favor by continental surgeons, and is said to be 
rarely followed by vomiting." (Hewitt.) 

In all forms of anesthesia one of the principal objections is the fact 
that the operator is led to ignore the flight of time, to the detriment of 
the patient. It should always be remembered that the shorter the 
operation and the smaller the amount of anesthetic given, the better. 
The patient once having been anesthetized, the rule to be borne in mind 
is the saving of time, animal heat, and the amount of anesthetic. Some 
patients are more prone to vomit after anesthesia than others. Accord- 
ing to Hewitt, rosy- cheeked children, young women of good color and 
full lips, and flabby-looking individuals with an unhealthy and dusky 
appearance are much more liable to postoperative vomiting than others. 
Such patients nearly always secrete large quantities of mucus and saliva. 
Thin, spare, and sallow 7 patients, those who have become anemic from 
exhausting diseases, and aged persons are not often nauseated after 
anesthesia. Patients of "bilious" habit frequently suffer a good deal 
after ether or chloroform. 

Lastly, the nature or extent of the operation has its influence upon 
the postoperative vomiting. Operations upon the intestines, oophorec- 
tomy, protracted laparotomies in which the bowels are exposed or freely 



84 POSTOPERATIVE TREATMENT. 

manipulated, or in which heavy metal retractors are used, predispose 
to postoperative sickness of more or less intensity. 

Special Methods of Prevention. — It is believed by good authority 
that 2tu to Tiro grain of atropin sulfate given under the skin before 
etherization lessens the tendency to nausea and vomiting materially. 
(Buxton.) "The administration of oxygen immediately after the 
removal of the anesthetic is a favorite practice with many physicians 
who claim that the period of recovery from the anesthetic is thereby 
shortened, and also that the nausea and vomiting are much diminished." 
("International Text-book of Surgery.") Lewinsays: " The vomiting 
is frequently due to swallowing of the mucus and saliva containing some 
of the anesthetic in solution. The anesthetic thus acts as a direct 
irritant to the stomach, and vomiting is induced by the elimination 
of the drug through the glands of the gastric mucosa." He suggests 
two plans to prevent this local effect: (i) a local anesthetization of 
the gastric mucosa, which may be done by lavage of the stomach with 
a solution of cocain of 0.05 gram to 0.1 gram cocain in 500 grams water; 
(2) protect the gastric mucosa from the direct influence of the anesthetic 
by the use of some indifferent substance which will form a coating over 
it. For this purpose he suggests the use of a mucilage of acacia, of 
tragacanth, salep, or a thick decoction of Iceland moss. By changing 
the position of the patient, all parts of the stomach can be reached. 
("Practical Medicine Series," vol. ii, 1901.) 

Treatment. — The patient should be kept quiet. If vomiting proves 
distressing, give a few sips of simple hot water or a small cup of hot tea. 
I have frequently known a draft of hot water or tea to relieve distress- 
ing retching. Hot coffee and champagne have also been recommended. 
Small doses of cerium oxalate or bismuth subnitrate, or calomel in small 
and frequently repeated doses, have proved at times highly beneficial. 
Cold water and ice should be avoided. In our experience they only 
tend to aggravate the trouble. Sometimes the application of an ice- 
pack to the epigastrium will give relief. The inhalation of vinegar 
has been of no value in our hands. Buxton speaks highly of the use 
of ten to fifteen grains of sodium bicarbonate dissolved in a little hot 
coffee. In the more aggravated cases, lavage of the stomach with a 
solution of sodium bicarbonate, together with a hypodermatic injection 
of morphin, has proved more effective than anything else we have tried. 
Linevitch advises washing out the stomach with lukewarm alkaline 
solutions. Blumbul employs plain water for the same purpose and 



POSTOPERATIVE SURGICAL SHOCK. 85 

speaks favorably of this treatment. I have lately tried lavage of the 
stomach with normal salt solution containing 1 : 1000 solution of adrenalin 
chlorid with very marked success. If there is a pronounced neurotic 
element in the vomiting following anesthesia, great benefit may be derived 
from the use of an enema composed of one teaspoonful of tincture of 
asafetida to one pint of hot water. Potassium bromid, twenty grains 
to two ounces of water, is recommended by Hewitt. 

POSTOPERATIVE SURGICAL SHOCK. 

General Considerations of Shock. — Some surgeons employ the term 
collapse as synonymous with shock; others employ it to designate a 
condition of shock produced by mental disturbance rather than physical 
injury. Crile regards collapse as an inhibition of the vasomotor center, 
in contrast to shock, which is exhaustion of the center. Pure collapse 
and pure shock may possibly be distinguished in laboratory experiments, 
but clinically the two are usually so closely combined as to render a 
distinction impossible, and, so far as the treatment is concerned, they 
are identical. 

The etiology of surgical shock has never been fully determined or 
satisfactorily explained. The condition is denned by Gould as a 
" relaxation or abolition of the sustaining and controlling influences which 
the nervous system exercises over the vital organic functions of the body, 
the result of a profound impression made on the cerebrospinal axis, 
either directly through the agency of an afferent nerve or through the 
circulatory system." 

According to Warren, "postoperative shock is a peculiar state of 
reflex depression of the vital functions, especially of the circulatory 
system, due to nervous exhaustion resulting from irritation of the per- 
ipheral ends of sensory and sympathetic nerves. There is also, appar- 
ently, exhaustion of the medulla and spinal cord followed by marked 
lowering of the vital powers." Goltz's experiments show that exhaustion 
or paralysis of the vasomotor centers in the medulla is the essential 
feature, and that this is produced in a reflex manner by disturbances of 
the sensory nerves. The degree of shock is, therefore, dependent upon 
the severity of the irritation as well as the length of time which this 
continues in existence. 

The above views are in accord with the consensus of modern opinion, 
but it is of vast clinical importance to remember that the diminution 
of the blood-supply alone or loss of vascular tone may be, and often is, 



86 POSTOPERATIVE TREATMENT. 

the most potent cause of serious and fatal shock; for if sufficient in 
quantity, the loss of blood weakens the heart-action and causes a dis- 
turbance of the entire circulatory system. The nervous phenomena 
in this class of cases are secondary to and dependent upon the loss of the 
blood-supply. 

Hewitt says: "In the treatment of shock, it is well to remember that 
the symptoms of shock which appear during or immediately following 
an operation are often so closely interwoven with those induced by toxic 
quantities of the anesthetic or those dependent upon asphyxia that they 
may easily be attributed to other causes, or, conversely, the toxic phe- 
nomena may be erroneously referred to surgical shock." The degree 
of shock may range from a mere temporary faintness lasting but a few 
moments to a more profound protracted condition that may eventuate 
in death. In determining the character of the shock, the condition of 
the system prior to the operation, or time required to complete the opera- 
tion, should be taken into consideration. 

Amputation following long-continued suffering and depletion of 
the system, especially after extensive compound fractures or infected 
wounds, double amputations or other mutilations following severe 
crushing injuries, nephrectomy, laparotomies in general, in ileus or for the 
removal of large tumors with intestinal adhesions, and, lastly, operations 
upon the brain and spinal cord, are especially liable to be followed by 
severe and prolonged shock. 

All operations should be performed as rapidly as is consistent with 
good surgery. The intestines should be exposed as little as possible, 
avoiding all minor measures known to increase shock, such as the use 
of large metal abdominal retractors, unnecessary jarring of the patient, 
the employment of dry, warm, sterilized towels and sheets, instead of 
those wet with aseptic solutions, to isolate the field of operation. ("Med- 
ical Summary.") Surgical shock may supervene at the moment of first 
incision, but in the majority of cases it does not appear until toward 
the close of the operation, or within from one-half to two hours imme- 
diately following. In rare instances, twenty-four to forty-eight hours 
may elapse, this condition being termed "delayed shock." 

General Symptoms. — The ordinary symptoms of postoperative 
shock in well-marked cases are about as follows: The patient may 
complain of chilliness, have a severe chill, or the symptoms may come 
suddenly without warning. The patient is cold, faint, and trembling, 
the face is pale and expressionless, pulse small and rapid. The surface 



POSTOPERATIVE SURGICAL SHOCK. 87 

of the body becomes moist with cold, clammy perspiration, the nervous 

system seems to be profoundly affected, the mental faculties show signs 
of disturbance, there may be incoherence of speech or delirium. There 
is usually difficulty in breathing, sighing respiration, and other signs 
of prostration. The body-temperature and pulse are the best guides 
to determine the severity of the shock, and should always be carefully 
noted. In the -average case the temperature usually falls one or two 
degrees. A fall of three or four degrees indicates a very critical condi- 
tion, recovery being exceptional. 

Preventive Measures. — When the condition of the patient or char- 
acter of the operation is such as to predispose to shock, or if there be 
sudden or unexpected loss of blood, or if from any other cause we 
recognize symptoms which indicate impending shock, preventive meas- 
ures should be adopted at once. Since the introduction of anesthesia, 
the severe forms of shock are not so frequently seen. A simple and 
efficacious measure for preventing shock is the repeated administration 
of brandy or whisky several hours preceding the operation. In cases 
in which we anticipate shock, an ounce of whisky in six or eight ounces 
of hot water, given ten to twelve hours before the operation and repeated 
once or twice at intervals of two or three hours, will usually secure a 
full pulse, allay all previous fear, and render the patient so susceptible 
to the anesthetic that but little will be required. The effects of this 
stimulant continue often from ten to forty-eight hours, and thereby 
prevent secondary shock and exhaustion. (Dennis.) 

In operations upon the brain, Dana believes that the danger of shock 
is lessened by getting through the skull without the use of mallet and 
chisel, yet Keen habitually employs the mallet and chisel in cranial 
surgery, without increased fear of shock from this source. Again, in 
cerebral surgery, as pointed out by Cushing, precise information upon 
the arterial tension is of value as indicative of approaching shock. In 
cases of collapse from the hemorrhage or shock, and during the course 
of severe abdominal operations, there is little doubt that similar infor- 
mation will be of value to the surgeon. Man}- forms of apparatus have 
been devised to serve this purpose. The Riva-Rocci instrument, which 
has been in use since 1896 in Italy, and which was introduced in this 
country in 1900, appears to have fewer defects and more advantages 
than the other instruments brought to our attention. No special train- 
ing is necessary to make observations with it, and so far as successive 
observations on the same patient are concerned, its accuracy is probably 



88 



POSTOPERATIVE TREATMENT. 



sufficient for clinical purposes. Dr. T. C. Janeway has recently devised 
a portable sphygmomanometer which employs the circular method of 




Fig. 6. — Janeway's Sphygmomanometer. 




Fig. 7. — Cook's Modified Riva-Rocci Apparatus for Determining Blood- 
pressure. 

A. Hand bulb for counter-pressure. B. Distended bulb. C. Rubber connect- 
ing tube. 

compression used in the Riva-Rocci instrument, together with the wide 
armlet recommended by V. Recklinghausen. 

The sphygmomanometer consists of three essential parts: 



POSTOPERATIVE SURGICAL SHOCK. 89 

A. Manometer, of U-tube form, with upper part jointed, fixed to the 
under side of case lid. The scale is graduated empirically for each 
manometer, and is accurate. 

B. Compressing armlets, consisting of a hollow rubber bag, 12x18 
cm. This is attached to an outer leather cuff, which fastens by two 
encircling straps with friction buckles. 

C. Inflator, an 8 oz. Politzer bag with valve. 

It may be that Cushing takes an enthusiastic view of the matter in 
his predictions that in appropriate cases the routine observations upon 
blood-pressure will soon come to occupy the same relative position that 
pulse and temperature occupy at present. ("Boston Med. and Surg. 
Jour.") 

General Considerations of Treatment. — The indiscriminate use 
of normal salt solution, strychnin, morphin, digitalin, nitroglycerin, 
and other cardiac stimulants, wmich has become a matter of habit with 
many surgeons, is mentioned only to be condemned. The recent 
experiments by Crile and the conclusions which he has drawn from a 
series of experiments have awakened general interest. Crile believes 
that the essential features of surgical shock are the exhaustion or paralysis 
of the vasomotor centers w T hich control the tone of the peripheral cir- 
culation. To the surgeon of today, the essential fact brought out by 
Crile's experiments is that strychnin, the stimulant universally employed 
in the treatment of shock, is practically of no value, and in pronounced 
cases may even increase the condition it is intended to relieve. This 
coincides fully wdth my personal experience, and I have long since 
discarded strychnin in certain varieties of shock except as a respiratory 
stimulant. 

For the convenience of the student, and with an effort to formulate 
a more practical and less incomprehensible understanding of this 
important subject, and in order that the reader may have a better con- 
ception of the principles governing the rational treatment of postoperative 
shock which the different causes and conditions require, I have divided 
the subject into four distinct classes: (1) Surgical shock due to vaso- 
motor depression, nervous exhaustion, or vital depression without 
serious hemorrhage; (2) shock as a result of hemorrhage; (3) postopera- 
tive shock from the toxic effects of the anesthetic ; (4) shock produced 
by mental disturbance — sometimes denominated nervous collapse. 

Surgical Shock Due to Vasomotor Depression, Nervous 
Exhaustion, or Vital Depression Without Serious Hemor- 



go POSTOPERATIVE TREATMENT. 

rhage. — The distinguishing features of this type of postoperative shock 
are : The patient immediately or within an hour or two following the 
operation passes into a condition of more or less profound prostration. 
The notable absence of hemorrhage sufficient to account for such con- 
dition, the distention of the veins, cyanosis, and the exclusion of possible 
narcosis from the anesthetic itself, render the diagnosis, so far as treat- 
ment is concerned, a matter of little difficulty. The temperature rarely 
falls more than one or two degrees below normal and the nervous symp- 
toms are markedly prominent. In other words, shock not accounted 
for by hemorrhage or narcosis from the anesthetic or other obvious 
causes, indicates general nervous reflex depression or vasomotor exhaus- 
tion; the indications for treatment must be directed to arousing or 
restoring to its normal condition the depressed nervous system. The 
patient, as in all other types of surgical shock, should be placed 
flat upon his back, and the entire body wrapped in warm blankets and 
surrounded on all sides with hot- water bottles. 

We object to the Trendelenburg position in this form of shock. The 
patient, especially if plethoric, when placed in this position will soon 
exhibit venous congestion of the face, which may tend to aggravate the 
condition. Capillary congestion of the skin may be relieved by vigorous 
rubbing, and cloths wrung out of hot mustard-water may be applied 
to the precordial region. 

Treatment of Shock Due to Depression. — Of all heart stimulants at 
our command for the adult, morphin, J grain, combined with digitalin, 
5^- grain has proved in my experience the most effectual. Adrenalin 
chlorid i : iooo, as suggested by Crile, injected into the infraclavicular 
or submammary tissues, in connection with morphin, has acted promptly 
and satisfactorily in the few cases in which we have used it. We pre- 
fer to administer adrenalin solution by the mouth (15 to 30 minims of a 
1:1000 solution every thirty minutes until reaction occurs). I have 
never been favorably impressed with the effects of strychnin in these 
cases; in fact, I now seldom give it except in combination with brandy, 
\ to 1 dram, and then only when there is embarrassment of respiration 
Atropin, -j-J-q grain, or spartein, \ to J grain, may be given with advan- 
tage. A high enema of warm normal salt solution with 20 to 30 minims 
of oil of turpentine will also prove of benefit, but hypodermoclysis or 
intravenous injections are usually not indicated. 

Shock as a Result of Hemorrhage. — This is the most fatal form 
of postoperative shock, depending in degree not solely upon the amount 



POSTOPERATIVE SURGICAL SHOCK. 91 

of hemorrhage, but complicated or increased by the symptoms of general 
shock or vasomotor exhaustion from the blood loss. It is this class 
of cases that taxes severely the resources of the attending surgeon. 
Unless the loss of blood has been very sudden or profuse, the symp- 
toms of shock do not develop as rapidly as one would expect. The 
general symptoms are about the same as heretofore described, except 
that there is a greater tendency to nausea and vomiting, and instead 
of venous congestion, we have the pallor of anemia. Respiration is 
usually feeble but not embarrassed, pulse rapid, feeble, of a running 
character, or absent at the wrist. There is usually intense thirst, tem- 
perature is at first normal, but decreases with the severity of the attack. 
The fact that there has been severe hemorrhage will warrant the belief 
that the loss of blood is the direct cause of the shock, and treatment must 
be in accordance therewith. 

Treatment 0) Shock Caused by Hemorrhage. — It is in this variety of 
surgical shock that so many lives have been sacrificed by erroneously 
resorting to drugs. To rely upon strychnin or other heart stimulants 
is folly. The recognition of hemorrhage or loss of blood is vital. The 
condition must be combated by the retention of a functioning amount 
of blood in the brain, especially in the respiratory centers. The head 
and shoulders should be promptly lowered. The Nelaton or Trendel- 
enburg position is best maintained by elevating the foot of the bed some 
inches. Neither pillow nor bolster should be left under the head. In 
desperate cases the limbs should be raised nearly to a right angle with 
the body, and thus held. Instead of this, ordinary muslin bandages 
may be applied firmly to one or all of the limbs, and compression of the 
veins and arteries maintained in this manner. Many fives could be 
saved if the more essential, if not all, of these measures were complied 
with in the first evidence of impending shock of this character. (Dennis.) 

Sudden pallor with increasing pulse-rate immediately following the 
loss of blood indicates the approach of shock, and the surgeon in charge 
should recognize at once that the life of his patient is in danger. The 
patient should be carried to his bed and surrounded, as in all cases of 
shock, with artificial heat ; and stimulants by the mouth or rectum should 
be given. Rectal enemas of hot water with turpentine act well. Sub- 
cutaneously, whisky, ether, atropin, or adrenalin will prove beneficial. 
If the hemorrhage has been severe, and the condition of the patient 
indicates further measures, hypodermatoclysis of normal salt solution 
is the best treatment. High enemas of warm normal salt solution 



92 POSTOPERATIVE TREATMENT. 

should also be administered every two or three hours, and in the more 
pronounced cases resort must be had to intravenous saline injection. 
As the patient rallies, the retentive bandages, if applied, may one by 
one be removed. The limbs are then lowered, but the dependent 
position is maintained until all risk of syncope has passed. As occasion 
permits, concentrated hot meat essence or milk, hot coffee, tea, etc., 
must be given — liquids which when absorbed will supply the heart with 
a bulk of fluid sufficient to go on with its function. 

Postoperative Shock from the Toxic Effects of the Anes- 
thetic. — Postoperative shock attributable to the anesthetic itself is 
of frequent occurrence, being the result of overdosage, idiosyncrasy, 
or physical condition of the patient from previous disease. The symp- 
toms usually appear during anesthesia, the effects of the anesthetic 
causing rapid reduction of arterial tension to such a degree as to cause 
cerebral anemia, and consequently paralytic cessation of breathing. 
(Hill.) The toxic effects of the anesthetic may, however, continue 
twenty-four to forty-eight hours or longer following the administration 
of the anesthetic, and it is this postoperative form to which I particularly 
desire to call the attention of the reader. The patient has the ordinary 
symptoms of shock, but of a milder type. Respiration is always more 
or less embarrassed, pulse slow, feeble, irregular, or intermittent. The 
symptoms characteristic of this form of shock are: Delayed resolution, 
embarrassed respiration, frequently of the Cheyne-Stokes character, 
depressed circulation. These, in the absence of hemorrhage, and 
especially if this condition follows a minor operation, make the diagnosis 
of toxemia from the anesthetic certain. 

Illustrative Case. — W. H., tailor, aged twenty-two, of slender build and 
nervous temperament, had a slight cough, heart-sounds and chest expansion 
good, pulse 72, respiration normal. Operation 8 a. m. — paraphimosis. Chloro- 
form was administered on Skinner's mask, anesthetic cautiously given. When 
about to commence the operation, the breathing ceased, and the face suddenly 
became livid in color and covered with perspiration, hands and limbs cold, 
pulse imperceptible at wrist. The legs and body were at once elevated, and 
an attempt to establish artificial respiration rapidly made. A subcutaneous 
injection of sulfuric ether was given, and amyl nitrite applied to the nostrils; 
the patient's lips were occasionally rubbed briskly with a towel, as recom- 
mended by Hewitt. After prolonged exertion, respiration returned, and the 
wrist pulse gradually reappeared, although at no time normal. The operation 
was then performed rapidly, the patient removed to his bed, and head kept 



POSTOPERATIVE SI RGICAL SHOCK. 93 

low. The conjunctival reflex was present, though very sluggish. Respiration 
continued very slow and of a Cheyne-Stokes character. Brandy was given 
by the rectum, and strychnin hypodermatically, also oxygen by inhalation. 
The patient remained practically in this half-conscious condition for fully 
thirtv-six hours; during this time and for several days immediately following 
there was difficulty in swallowing, and nourishment had to be administered 
by the rectum. At no time was there nausea or vomiting. Resort to artificial 
respiration was repeatedly necessary. The ultimate result was recovery. 

Treatment of Shock Caused from Anesthetization. — I have been thus 
explicit for the reason that I have found these cases constantly over- 
looked, though of quite frequent occurrence. The treatment for this 
class is that already mentioned for surgical shock due to vasomotor 
depression, viz.: partial inversion, artificial respiration, exhibition of 
oxygen, and application of warmth, etc. If the patient is thin, feeble, 
and anemic, the intravenous introduction of saline fluid, or hypoder- 
moclysis, with strychnin, adrenalin, or digitalin, is indicated. (Hewitt.) 

Shock Produced by Mental Disturbance. — Neurotic and alco- 
holic patients, or those of a very timid character, especially females and 
children, even after trivial operations, frequently exhibit all the phe- 
nomena of pronounced surgical shock. Fortunately, fatal cases are 
exceedingly rare, the usual type being mild and transient in character. 
Excessive joy, grief, anger, or fear, may give rise to prostration varying- 
in severity like that of traumatic or surgical origin. The introduction 
of a sound into the urethra has been followed by death in a few hours, 
and the introduction of an aspirating needle into a pleura filled with 
fluid has been followed by immediate death. So has the opening of an 
abscess of the ringer. Relaxation of the sphincters, polyuria, or induc- 
tion of profuse diarrhea may be cited as instances of psychic shock from 
mental or emotional causes. The state of mind at the time of the opera- 
tion influences materially its effects upon the nervous system, and as the 
sensibility of pain varies greatly, so will the postoperative shock. In 
the language of Jordan, "Where nerve force is predominant, shock also 
becomes predominant." It is characteristic of this variety of shock 
that it is often late in developing. The diagnosis is ordinarily easy 
in the presence of restlessness and excitability, the characteristic expres- 
sion of the face, especially in children, in the absence of hemorrhage 
or anesthetic narcosis, and especially when we have reason to believe, 
from the character of the operation, that the nature of the shock must 
of necessity be of neurotic origin. I have never seen a fatal case of 



94 POSTOPERATIVE TREATMENT. 

postoperative shock as the result wholly of psychic causes. Travers, 
however, describes cases of this character which he characterizes as 
"shock or prostration" with excitement; the patient, while conscious- 
ness lasts, is wild with anxiety, changing his position and struggling 
for air or breath, and oblivious to everything but his impending fate. 
Usually delirium of a muttering or violent kind supervenes, and the 
scene ends in coma. This form of surgical shock is frequently encount- 
ered in excessive drinkers, and in the wards of our public hospitals. 
It is seen in fully one-fourth of the fatal cases of shock. (Hare.) 

Treatment of Psychic Shock. — If the disturbance is chiefly mental, 
the patient, especially if a child, will usually rally speedily if spoken to in 
a kind and cheerful manner. The principles already enunciated in the 
treatment of the first class of postoperative shock are applicable to this 
kind. All active measures or excitement should be avoided, and rest 
and perfect quiet, as far as possible, should be enforced. Rectal injec- 
tion of tincture of asafetida, one dram to a pint of hot water, or twenty 
to thirty grains of potassium bromid every two or three hours, are highly 
recommended in shock of this character. The alleviation of pain with 
morphin, J to J grain, preferably combined with atropin, is frequently 
necessary and tends to hasten reaction. 

GENERAL POSTOPERATIVE CONDITIONS. 

Acute dilatation of the stomach is a condition which sometimes 
follows prolonged administration of an anesthetic, and when accom- 
panied with shock may cause grave symptoms, which if not promptly 
relieved may speedily terminate in death. I have been astonished at 
the frequency with which dilatation occurs, and yet this fact has not 
been recognized or noted by writers upon this subject, so far as I have 
been able to ascertain. The symptoms usually make their appearance 
from eight to twelve hours after anesthesia. In patients, as a rule, 
who have not vomited, dilatation comes on rapidly, pressure of the 
dilated stomach causing marked distress and disturbance of the heart, 
the lungs, and the portal circulation. Dyspnea and palpitation of the 
heart are prominent symptoms, and increase according to the extent 
to which the diaphragm is forced upward by the stomach distended 
with gases. If this condition continues uninterrupted, the intestines 
become involved until there is a general condition of paresis with symp- 
toms of tetany. Tabes facialis is marked and the pulse is greatly in- 



GENERAI POSTOPERATIVE CONDITIONS. 95 

creased. Temperature may be but slightly elevated, normal, or sub- 
normal. Palpation readily reveals the trouble, there being marked 
resonance over the stomach, dust and colon — so marked, indeed, as to 
be audible for some distance from the patient. 

The following case of recent occurrence is typical of the condition: 

Mrs. B., aged thirty-four, medium height, well nourished, weight about 
145 pounds, blond. Operation 8 a. m. A large fibroid tumor involving both 
ovaries was removed. The tumor was adherent to the bladder and a portion 
of the small intestines. The anesthetic used was Squibb's ether; length of 
administration, one hour and thirty-seven minutes. The patient took the 
anesthetic well; no vomiting; normal salt solution administered by the rec- 
tum at the close of the operation. The patient rallied well, shock not 
marked, but complained of great thirst, which was controlled by sips of hot 
water. At 2 p. m. she declined the hot water, complaining of distress in her 
stomach. At 6 p. m. she vomited profusely and felt very much relieved. I 
was called again at 11.30 p. m.; found the patient in great distress, pulse 
140, temperature 97.6. Dyspnea was pronounced; the patient was very rest- 
less, could not lie down, face pale and haggard, marked tympanites over 
entire chest and stomach, slight twitching of facial muscles and muscles of 
forearm and fingers, forehead cold and clammy, apparently in a serious con- 
dition. Upon the introduction of the stomach-tube gas escaped in large 
quantities. A warm solution of sodium bicarbonate was used, the stomach 
thoroughly washed out, and morphin, J grain, with digitalin, ^5- grain, 
administered hypodermaticaHy. Relief was immediate and permanent. 

Postoperative Thirst. — Postoperative thirst is a matter of great 
annoyance to the patient, in fact, frequently causing distress more 
difficult to bear than pain itself. DaCosta and Kalteyer have shown 
that directly after anesthesia the watery elements of the blood are 
diminished. This result is peculiar to chloroform and ether when 
introduced into the blood either by inhalation or by injection; they also 
retard the oxygen- carrying elements of the blood and have a direct 
effect upon the nerves and cerebrospinal centers, impairing both in 
direct ratio to the amount of anesthetic used. Postoperative thirst 
is therefore nearly always the direct result of the anesthetic, and this 
condition is increased in proportion to the amount of blood lost during 
the operation. Prolonged anesthesia and loss of blood are the prime 
factors in causing this most unpleasant after-symptom, and in our 
experience the thirst following ether is greater and more prolonged than 
after chloroform administration. 



96 POSTOPERATIVE TREATMENT. 

To overcome or prevent postoperative thirst has been a subject of 
inquiry for a long time. It is our custom always to wash out the stomach, 
after which a high rectal enema of warm salt solution is given. This 
procedure is universal after all major operations, and before the patient 
is removed from the operating table. This is done not only to prevent 
shock and to stimulate the system, but to relieve postoperative thirst. 
I have often noted after laparotomies in which flushing of the abdominal 
cavity with hot sterile water is done, and especially when the major part 
of the fluid is allowed to remain, that the respiration and pulse usually 
improve and postoperative thirst is greatly lessened. After the patient 
has partly regained consciousness, the occasional sipping of hot water 
will frequently give relief or allay the extreme thirst, but cold water even 
in small quantities invariably causes violent retching and vomiting. 
If the hot water does not suffice, a little champange, hot tea or coffee,, 
or, lastly, the holding of cold wet cloths in the mouth, or frequently 
bathing the lips and rinsing out the mouth with cold water, may suffice 
for the first six or eight hours, after which time, if all tendency to vomiting 
or retching has ceased, a trial of a few sips of cold water may be given; 
if successfully retained, this may be increased until the patient's wants 
in this respect are satisfied. 

Of the new remedies suggested for the relief of postoperative thirst, 
chloretone seems destined to become the most popular. A five-grain 
capsule given one-half hour before anesthesia, followed by a three- 
grain capsule as soon as the patient regains consciousness, has proved 
very successful in the few cases in which we have used it, but in our 
experience there is no remedy equal to lavage of the stomach repeated 
as often as required. 

Postoperative Use of Morphin. — The judicious use of morphin, 
hypodermatically administered, is of inestimable postoperative value 
in nearly all major cases. I am well aware that many celebrated sur- 
geons denounce the use of morphin in any form, asserting that it stops 
peristalsis, locks up the secretions, increasing thereby the danger of 
infection, and greatly augments the death-rate. Neither actual facts 
nor clinical history warrant such assertions. 

It has been my experience that morphin is frequently indispensable 
not only to relieve acute postoperative pain, but for the relief of exhaus- 
tion or general nervous restlessness which frequently follows prolonged 
operations. I have seen numerous instances in which, after even an 
ordinary laparotomy, the patient became exhausted, nervous, or rest- 



GENERAL POSTOPERATIVE CONDITIONS. 97 

less, with or without acute pain; the heart-action became rapid and the 
temperature rose to 102 , 103 F., or higher. In such cases a hypo- 
dermatic injection of J to J grain of morphin produces a quiet, refreshing 
sleep, from which the patient often awakes with a normal temperature 
and pulse-rate. 

Indications for the Use of Morphin. — No fixed rule governing 
the postoperative use of morphin is possible. It should be administered 
only when actually necessary, and subsequently repeated as infre- 
quently as possible. No morphin should be given, as a rule, until 
the patient has fully recovered from the immediate effects of the anes- 
thetic, and the mouth, throat, and air-passages are free from mucus 
and saliva. During the period of reaction pain is frequently acute, but 
usually transient in character, hence morphin should be withheld. If 
later the patient suffers severely or is very restless, •§- to J grain of morphin, 
if given subcutaneously, will afford great comfort to the patient. Large 
doses may be needed in exceptional cases. 

The susceptibility of the patient to the drug or peculiar idiosyncrasy 
should be borne in mind. Morphin is especially indicated after ampu- 
tations following severe crushing injuries or in severe postoperative 
pain of any character, and especially after removal of the ovaries or 
uterus, in which the pain which follows is sometimes excruciat- 
ing. The use of morphin in conjunction with digitalin in my hands has 
proved of greater service as a heart stimulant than strychnin or nitro- 
glycerin. In postoperative hysteria or extreme restlessness from any 
cause the modifying influences brought about by morphin will be suffi- 
ciently obvious. The supposed ill effects caused by morphin checking 
the secretions or inhibiting peristalsis, etc., may be partly overcome by 
combining strychnin with the morphin. The administration of morphin 
must be watched with care and the drug given only in sufficient quanti- 
ties to accomplish the purpose intended. 

Surgeons are too prone to early medication and feeding after opera- 
tion. Dr. Joseph Price says: "Fuss and feathers and meddlesome 
management are foolishness. Quiet, absolute, on the back, with nothing 
for twenty-four hours but those little attentions from a skilled nurse to 
relieve irksomeness, to provide a cool back, well-rubbed limbs, an empty 
bladder, a fresh mouth by rinsing, with no opium in the house, will 
give a cheerful and comfortable patient. It should be noted that patients 
with the opium habit are highly deceitful, untruthful, and are to be 
managed by the individual skill of the operator." 

7 Lora 



CHAPTER V. 

TREATMENT OF ASEPTIC AND SEPTIC 

WOUNDS. 



CHAPTER V. 
TREATMENT OF ASEPTIC AND SEPTIC WOUNDS. 

Postoperative Treatment of Wounds. — The after-treatment of 
wounds depends somewhat upon whether they are aseptic or septic, and 
in either case their care deserves close attention to detail. Operative 
wounds are rarely infected if only reasonable care is taken at the time of 
the operation. In the changing of dressings the surgeon and his assist- 
ants should always observe the same care and aseptic regulations that 
they do when about to perform a surgical operation. Before the wound 
is exposed, and before the deeper dressings are removed, the bedding 
and underclothing should be covered with sterile towels and excluded 
from possible contact with the wound. The patient's hands must be 
carefully watched or placed where they may do no harm; the instru- 
ments and dressing materials must be in perfect condition. Articles 
such as bowls, irrigators, syringes, etc., should be absolutely free from 
infection. 

The dressing of aseptic wounds, unless loosened or soiled, need not 
be changed until the time has arrived for the removal of the stitches, 
or seven to nine days after the operation. Incisions upon the face, 
neck, or hand heal much more rapidly. The dressings and part of the 
sutures may be removed the second or third day. When there is great 
tension of the skin, in large or ragged wounds, the stitches may be left 
ten to fourteen days, especially if the skin around the wound does not 
appear well nourished or the scar firm. Some surgeons are in the habit 
of changing the dressings the second or third day following the operation. 
This is ordinarily unnecessary, and only tends to annoy the patient. If, 
however, at any time the dressings are soiled, or if during the repair 
or healing of the wound the patient should become chilly or have a rigor, 
or if there is pain, general restlessness, or sudden rise of temperature, 
the dressings should be immediately removed, and the wound carefully 
inspected. If the wound is found infected and inflamed, a sufficient 
number of stitches should be removed to admit of the free escape of pus 
if present, and relieve the tension of the skin. No antiseptic irrigation 
should be attempted at this time. The skin and surface wound should 

IOI 



102 POSTOPERATIVE TREATMENT. 

be cleansed with a solution of hydrogen dioxid, or the wound may be 
gently irrigated with a hot solution of sterilized normal salt solution. 
(For the treatment of more pronounced infection, cellulitis, erysipelas, or 
septicemia, the reader is referred to articles upon these special subjects.) 
In amputations, or following septic operations, when drainage is 
expected or abundant, the dressings may require to be changed in 
twelve to twenty-four or forty-eight hours. Dressings should be removed 
when soiled, regardless of time, and changed as often thereafter as indi- 
cations seem to warrant. After dressing of pus-cavities or open wounds, 
if packed with gauze, especially appendicular abscesses, it is little less 
than cruelty to attempt the removal of the gauze in less than four to 
six days, when adhesions form and the gauze will become loose, admit- 
ting of painless removal and repacking. In aseptic wounds the dressings 
should be removed in from seven to nine days, and if the gauze adjacent 




Fig. 8. — Andrews' Scissors. 

to the incision adheres, it is best to soak it well with hydrogen dioxid 
before removing it, the wound being immediately recovered with a clean 
piece of gauze. If, now, the wound appears to be thoroughly healed, 
the stitches may be removed. The stitches are cut close to the skin 
upon the side below the knot, and if of silkworm-gut, by twisting gently 
and by following the curve of the stiff suture, their removal will cause 
very little pain. The removal of deep-seated or imbedded sutures is 
greatly facilitated by means of Andrews's scissors (an ingenious inven- 
tion of Dr. Frank Andrews, of Chicago). The employment of these ena- 
bles the surgeon with a little practice to grasp the knot firmly and sever 
but one side of the suture below the tie. It is sometimes advisable not 
to remove all the stitches at one time. If all the stitches are removed, 
and if the wound is found to be dry, firm, and healthy in appearance, 
a piece of dry gauze the required shape and size should be placed over 
the entire wound and the whole fixed with flexible collodion. Should 



TREATMENT OF ASEPTIC AND SEPTIC WOUNDS. IO3 

there be any gaping of the skin wound, the edges should be drawn 
together with small strips of sterilized zinc oxid adhesive plaster, and 
the wound dressed as before. 

After-treatment of the Wound. — Sir Frederick Treves says (" Oper- 
ative Surgery," vol. i): 

"Immense progress has been made of late years in the treatment of 
wounds.. In this progress the most prominent figure is that of Lord 
Lister. To him belongs the honor of having effected a reformation in 
surgery, of having established upon new and scientific basis the ancient 
art of healing, of having freed the operator from the more grievous of 
the dangers which surround him, and of having greatly extended the 
powers and possibilities of the surgeon's art. 

"As to the exact method of dressing a wound, and the materials to 
be used in that dressing, it is impossible to be dogmatic. 

"Probably at no time have the modes of dealing with wounds been 
more numerous, nor has the application of a few common principles 
been more diverse. 

"All surgeons endeavor to secure that the wound shall be quite clean; 
shall be aseptic; shall not be irritated; shall be kept at rest. One sur- 
geon accomplishes these ends in one way, another in another, and the 
results are equal. He who considers that his method of dealing with a 
wound is the most perfect will find that his neighbor, who adopts very 
different details, obtains an identical measure of success. New anti- 
septic agents appear from time to time upon the scene. They are pur- 
sued, are vaunted as perfect, are diligently employed, and then not a few 
of them fade away, some very gradually, others with the suddenness of 
the South Sea Bubble. 

"In the after-treatment of the operation wound the part must be kept 
absolutely at rest. Mere confinement in bed, with the support of a 
proper pillow, may suffice to effect this, or a special splint or retentive 
apparatus may be employed. The part is kept raised, so that the cir- 
culation of the blood through it may be as much relieved as possible, 
and is so placed that drainage, if arranged for, may be readily effected. 
The wound itself is simply dusted with iodoform, and is covered with a 
thick layer of dry, sterilized wool. Next to the skin a layer of Tillmann's 
sterilized paper dressing is applied, for the excellent reason that it never 
sticks to the wound. A bandage is then so applied as to bring pressure 
to bear upon the wound. The effect of this is that the edges of the 
incision are kept well together, the cavity of the wound is obliterated, 



104 POSTOPERATIVE TREATMENT. 

any tendency to oozing is prevented, the use of a drainage-tube is 
unnecessary, and the parts concerned in the wound are kept perfectly 
at rest. 

"The 'domer bandage is best suited for the majority of cases. The 
bandages used are often unnecessarily thick, and hence in hot weather 
uncomfortable, fc Those made of thin 'butter-cloth' muslin are very 
light and cool.JjjFor fixing dressings on the head, neck, and many other 
parts they cannot be surpassed. There should be a liberal covering of 
wool, as it tends to equalize and diffuse the pressure employed. The 
amount of pressure employed must depend upon the circumstances of 
the individual case. Unlimited pressure would obviously not be em- 
ployed in cases in which the vascular supply of the part is slight and the 
patient very old. In certain regions — e.g., the groin — one or more 
turns of elastic webbing bandage over the ordinary one will be found 
useful for maintaining even pressure. 

"For the last ten years (as recommended by certain American sur- 
geons) I have made a practice of keeping the wound absolutely dry 
from beginning to end. Microorganisms cannot grow without moisture, 
and moist dressings and washing of the wound provide this medium. 
To illustrate the matter by an abdominal incision, the procedure is as 
follows : The operation area is surrounded by hot, dry, sterilized towels. 
The sponges used are artificial sponges made from gauze, which are 
almost free of moisture. 

'"After the sutures are introduced the wound is dried, dusted with 
iodoform, and covered with a thick dry dressing of cotton-wool and 
Tillmann's paper. The bandage or binder is applied firmly. The 
wound is dressed again on the fourth or fifth day. The dry dressing 
falls off, and by means of dry forceps the wound is cleared of the caked 
iodoform powder and little dried blood which cover it. As a matter of 
fact, the forceps will 'clean ' such a wound quicker and more efficiently 
than a prolonged washing. 

"Iodoform and another dry dressing are again applied, and from the 
perfectly dry wound the sutures are removed on the eighth to the tenth 
day. In my experience no method of dealing with wounds has given 
such uniformly successful results as this. The simpler wounds, such as 
those following the ligature of an artery or the removal of a small growth, 
need not be disturbed for a week. If much oozing be anticipated in 
any case, the wound may be dressed at the end of twenty-four hours, 
and then left for four or five davs. 



TREATMENT OF ASEPTIC AND SEPTIC WOUNDS. 105 

"Sterilized gauze or gauze charged with mercury bicyanid is used 
very widely as a dressing, and answers admirably. It is the rarest thing 
to see any irritation of the skin produced by the cyanid, but the results 
from the use of simple sterilized gauze seem to prove that the antiseptic 
is unnecessary provided all other precautions are taken. 

"Tillmann's 'paper dressing' or 'dressing linen,' already alluded to, 
is an admirable application for all wounds. It is soft and compressible, 
and very absorbent, and possesses the great quality of not sticking to 
the wound." 

Jonathan Hutchinson, Jr., of the London Hospital, says: "An 
ideal dressing for wounds in which some oozing is certain to occur — e. 
g., excisions of joints — is afforded by a moist sterilized gauze bandage. 
This is dipped in weak carbolic solution, and applied directly over the 
wound, and made to cover the limb above and below for some distance. 
As the bandage dries it contracts, and therefore it must not be employed 
too tightly. Absorbent wool is applied outside this bandage, and secured 
with a second one. 

"The wounded part should be kept in the open air — i.e., should be as 
far as possible uncovered by the bedclothes. This will be more or less 
inevitable with wounds of the head, neck, and upper extremity. The 
lower limb, after operation, should be quite uncovered by the bedclothes. 
The atmosphere under bedclothes is limited, is hot, is moist, and is 
frequently foul, as after the use of the bedpan. The exposed limb may 
be wrapped up during the cold weather, and in my wards, where no 
wound of the extremities was ever allowed to be covered by bedclothes, 
I never heard any complaint on the ground of the part being unduly cold. 

"In operations about the pelvis, such as castration and the radical 
cure of varicocele, the part can be kept in a reasonably healthy atmos- 
phere by a simple arrangement of the clothes over a bed- cradle." 

In minor or surface sepsis following operations Pryor recommends 
the following method of treatment (Pryor's "Gynecology," page 293): 
"If the sepsis has resulted from a plastic operation the wound should be 
carefully examined, and if evidences of infection are present the sutures 
in the center of the involved area should be at once removed and the 
edges of the wound separated sufficiently to allow of irrigation of the 
wound. It may be the infection will be about one suture only, but 
sufficient sutures must be removed to enable the operator to wash out 
the wound and apply his dressings, even if all must be removed. A 
dressing which was devised by the late Professor Van Arsdale has no 



106 POSTOPERATIVE TREATMENT. 

equal. For instance, assuming the infection to be in the surface of a- 
laparotomy — and most of them are between the skin and fascia — 
enough sutures are removed to expose the involved parts, and after alL 
pus is washed out and the edges of the wound irrigated with normal salt 
solution, the wound is thoroughly dried. Into such a cavity gauze 
soaked in a mixture of balsam of Peru i part and castor oil 8 parts is 
introduced, and the whole covered with rubber tissue. This dressing 
must be renewed every day. Bacteriologic examinations of many 
thousands of cases have shown that even the most virulent types of 
streptococcic infection have been controlled by this simple method of 
treatment. If the infection is in the cervix after amputation, all sutures 
should be ripped out and the surface painted with pure carbolic acid 
and the vagina packed with strong iodoform gauze. If after perineor- 
rhaphy the wound becomes infected sufficient stitches must be removed 
to allow of irrigation." In short, surface infections are to be treated 
by evacuation and drainage and the application of such sterilized prep- 
arations as have been found appropriate to the location in which the 
infection has taken place. 

Principles which Govern the Treatment of Infected Wounds. — 
This subject is well epitomized by J. Chalmers DaCosta, who in a clinical 
lecture says: 

"A wound made by the surgeon after the parts have been carefully 
prepared for operation is a clean wound, and irritating antiseptics should 
never be introduced into it. The wound edges are carefully approx- 
imated, drainage being introduced only if the wound is extensive;, 
if there exist in it dead spaces that cannot be satisfactorily obliterated by 
pressure; if the patient is very fat; or if the skin is so tender that it is 
obviously incapable of withstanding moderate pressure. The wound 
is dressed with dry, aseptic dressings. These points have previously 
been dwelt upon. 

"Every wound inflicted by an accident is regarded as contaminated 
from the very beginning. Such a wound undoubtedly contains numbers of 
bacteria. If it is not properly treated, there will be subsequent sup- 
puration of the tissues or putridity of the blood-clot and of the discharges; 
and it may even be that there will develop some grave condition, such as 
tetanus, erysipelas, septicemia, or pyemia. It is the surgeon's duty 
to cleanse with the utmost care an accidental wound. 

"In treating such a wound, we follow the formula already laid down. 
In the first place, if the hemorrhage is dangerous, it is temporarily 



TREATMENT OF ASEPTIC AND SEPTIC WOUNDS. 107 

arrested; in the second, if there is serious shock, we adopt the proper 
measure to obtain reaction; in the third, we remove foreign bodies and 
cleanse the wound; in the fourth, we permanently arrest hemorrhage 
and, finally, we provide for drainage, consider the question of approx- 
imating the edges, and apply the dressings. 

"The methods of cleansing such a wound depend somewhat upon 
the nature and the situation of the injury. In an ordinary, clean-cut 
incised wound, inflicted, let us say, with a razor or a penknife — an 
instrument, that is, of course, dirty, but is not likely to be covered with 
malignant bacteria — we should scrub the skin about the wound with 
soap and water, wash it with alcohol, and scrub it with corrosive subli- 
mate solution, the solution being hot and of a strength of 1 : 1000. The 
wound itself should be irrigated with a hot solution of corrosive subli- 
mate of the same strength. It should then be irrigated with a normal 
salt solution, to remove the excess of corrosive sublimate. 

"In any region but the face, drainage should be provided for, either 
by pieces of iodoform gauze or by a drainage-tube. Such a wound 
about the face may with safety be completely sutured, because the blood- 
supply is so excellent. In a wound of the scalp, however, capillary 
drainage should always be provided for by the insertion of silkworm- 
gut. It is necessary to drain these wounds, unless they are on the face, 
even though the infection has not been gross; because the necessary 
introduction of an irritant antiseptic causes a certain amount of tissue 
necrosis, and increases considerably the flow of wound-fluid. If egress 
for this fluid is not obtained, the wound will become unhealthy and will 
not undergo aseptic repair. 

"In dealing with a lacerated wound the surgeon carefully examines 
all the damaged tissue, and the tissue that he regards as hopelessly 
damaged should be cut away with scissors; for if such tissue is allowed 
to remain, it becomes necrotic and makes infection inevitable. A 
lacerated wound should be irrigated with corrosive sublimate and washed 
with salt solution, and should then have dusted into it iodoform, which 
may serve to retard the putrefaction in necrotic masses which, to a 
greater or less extent, are certain to form. It is never closely approx- 
imated with sutures. In many instances no sutures are used, the wound 
being left wide open; in other cases a few sutures are inserted. Such 
a wound should be drained by inserting a piece of iodoform gauze. 

"A punctured wound is very dangerous, even when there are but few 
bacteria. It cannot be cleansed unless enlarged by an incision. The 



108 POSTOPERATIVE TPvEATMENT. 

rule of treatment in these cases is to sterilize the skin; to make a free 
incision to the very depths of the puncture; to moisten the skin- edges 
with alcohol; and to swab out the wound with pure carbolic acid. Half 
a minute after the acid has been introduced the wound should be swab- 
bed with alcohol. The great germicidal value of carbolic acid has long 
been known, and the antidotal effect of alcohol has been demonstrated 
by Seneca Powell, of New York city. Such a wound must, of course, 
be drained; and this is usually accomplished by inserting a strand of 
iodoform gauze. 

"The details of the management of other forms of wounds and of 
wounds in particular regions will be discussed under the proper head- 
ings. It is necessary, however, to refer here to wounds that are grossly 
infected by the introduction of, for example, street dirt. Ordinary 
methods of cleansing will in such a case prove perfectly futile, and the 
following plan should be pursued : Sterilized olive oil is poured into 
the wound, after which the wound itself, as well as the skin around it, 
is scrubbed with soap and water. The oil entangles the masses of dirt, 
and the soap and water removes the oil with the dirt. After this has 
been done, the wound may be irrigated with corrosive sublimate, and 
then with normal salt solution; or, what is better, it should be first swab- 
bed with pure carbolic acid and then washed with alcohol. The skin 
about the wound is cleansed in the usual manner. 

"A primarily infected area should be dressed with hot antiseptic fomen- 
tations. The use of heat in such an area is of the first importance: it 
lessens pain, diminishes stasis, increases the activity of the leukocytes, 
favors migration, and brings hordes of leukocytes to the part; and the 
leukocytes not only carry away dead material, but actively attack bacteria 
and surround the area of infection with an encompassing protective bar- 
rier. We therefore employ hot, moist dressings until the wound-dis- 
charge is seen to be thin and scanty; and until we are sure that con- 
stitutional symptoms will not develop, or until developed constitutional 
symptoms have passed away. Then, the wound having become an area 
of granulation-tissue, we can substitute dry aseptic dressings. 

"Rest is of the very greatest importance — rest in bed for a severe 
wound, and rest upon splints for a wound of the extremities. Rest in 
bed lessens the force and the frequency of the heart-beats, diminishes 
the amount of blood sent to the inflamed area, and conserves the patient's 
strength, . consequently increasing his vital resistance. The use of rest, 
either in bed or upon splints, by lessening or preventing muscular motion, 



TREATMENT OF ASEPTIC AND SEPTIC WOUNDS. IO9 

diminishes the danger of the breaking-down of the protective barrier 
of leukocytes that lies between the wound and the system at large. 

"If in spite of all this care a serious infection ensues, and the wound 
becomes unhealthy or the patient develops constitutional symptoms, 
we must apply such methods of treatment as I have previously discussed. 
The surgeon may be called to see a patient that has received a wound 
a number of days before and whose wound is already diseased. When 
a wound of this sort begins to show evidence of infection, the surgeon 
should promptly interfere. The evidences of infection are pain, which 
becomes pulsatile; discoloration, which becomes dusky; swelling, which 
at an early date will be accompanied with edema of the skin; and con- 
stitutional evidences of surgical or suppurative fever. 

"If such a wound has been closed with sutures, some or all of them 
should immediately be cut, so as to afford drainage. The wound must 
be gently irrigated with warm normal salt solution. Irritant antiseptics 
are not used. They are of value in preventing infection, but of little 
use when infection has occurred, and they may do harm by destroying 
the barrier of leukocytes. Drainage is to be secured by introducing 
a drainage-tube or strands of iodoform gauze. If the wound is putrid, 
iodoform should certainly be used. The part must be placed at rest 
and dressed with antiseptic fomentations." 



CHAPTER VI. 

ADJUNCTS OR AIDS IN POSTOPERATIVE 
TREATMENT. 



CHAPTER VI. 

ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT. 

Hypodermatoclysis. — Hypodermatoclysis is the introduction of 
saline fluid into the subcutaneous cellular tissue. The fluid may be 
introduced by means of a fountain syringe and an aspirating trocar and 
cannula, but best by a fountain syringe and a properly fitting hollow 
needle. After the skin has been sterilized, the trocar or needle is plunged 
into the subcutaneous tissue of the loin, buttock, subscapular region, 
or submammary region. The best region to use for this injection is 
perhaps the iholumbar, the space between the crest of the ilium and the 
twelfth rib. It is practically the point of least motion in the body, 
and does not interfere with the dorsal position or cause pain through 
movements of the limbs or from abdominal or thoracic respiration. 
The trocar, if this is used, is withdrawn, the cannula being left in place. 
A fountain syringe previously filled with hot sterile salt solution is used. 
The ordinary formula used is a 0.6 percent salt solution in boiled and fil- 
tered water. One dram of the solution to one pound of body- weight is 
the maximum quantity that should be used at one time, administered at 
a temperature of 108 to no° F. Some surgeons prefer the addition of 
25 percent sodium carbonate to 75 percent salt solution, as recommended 
by Tavel, especially for the irrigation of fresh or infected wounds. 
Others prefer plain sodium chlorid, the proportion of which should be 
not less than 6 percent or more than 9 percent. It is still an unsettled 
question which is the best. A larger percentage of salt is irritating 
and increases the danger of necrosis. The stock solution used in 
Halsted's clinic is as follows: Sodium chlorid 9. part, potassium chlorid 
0.03 part, calcium chlorid 0.01 part, distilled water 99.06 parts; 50 c.c. 
of the stock solution is added to 95c c.c. of distilled water. After steril- 
ization it is ready for use. The formula introduced by F. S. Locke 
has proved most efficacious in our hands. It is as follows: Calcium 
chlorid 0.25 gram, potassium chlorid 0.1 gram, sodium chlorid 9. 
gram, water 1 liter. The tube of the syringe is attached to the trocar, 
and the reservoir is hung several feet above the level of the bed. The 
fluid should run in very slowly, and absorption will be greatly facilitated 
8 113 



H4 



POSTOPERATIVE TREATMENT. 



by occasionally massaging the infiltrated area. After about a pint has 
been introduced, the cannula is removed, and the small puncture in the 
skin is closed with collodion. If the condition of the patient is such 
that more than a pint must be given, the operation is repeated in another 
region. 




Fig. 9. — Howard A. Kelly's Saline Infusion Apparatus, Consisting of a Grad- 
uated Glass i Reservoir Fitted with Stopper and Force Bulb, with Rub- 
ber Tubing, Pinch-cock, and Needle Attached. 



The rapidity of absorption depends considerably upon the condition 
of the circulation, and with a rapid or feeble heart with poor action of 
the capillaries, it is a much slower method than enteroclysis. The 
danger of overdistention here becomes important. If, however, in 
such a case with the hypodermoclysis we combine enteroclysis with 
normal salt solution at a temperature of 120 F., the heart is immediately 
started up and absorption of the subcutaneous fluid occurs more rapidly. 
For practical purposes the fluid may be injected once, twice, or three 
times during twenty-four* hours, depending upon the reaction and the 
rapidity of absorption. In an adult six ounces to a pint is indicated in 
uremia and allied conditions ; from a pint to a quart, if there is shock or 
hemorrhage. Gentle peripheral massage assists absorption. As there 
is considerable loss of heat in passing through the tube, the fluid should 
be at a temperature of from 115 to 120 F. Indications for stopping 
the flow may be deduced from the effects produced by the procedure. 



ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT. 115 

Subcutaneous injections increase the quantity of fluid in the vessels by 
replacing that which has been lost by hemorrhage. It adds to the 
circulation, and, therefore, stimulates a rapid and feeble heart, as in 
shock; it dilutes the poison and aids in eliminating toxic products through 
its diuretic action, as in sepsis or uremia ; it is asserted by many to have 
a hemostatic effect, and hence is of benefit in various kinds of hemor- 
rhage. Hypodermoclysis is an operation that should be performed 
with care and close attention to detail. All dangers of infection may 
be avoided by proper sterilization of the apparatus used, the solution, 
and the skin of the patient. 

Intravenous Injection. — Intravenous injection of saline fluid is 
especially indicated in shock, hemorrhage, sepsis, and suppression of 
urine. One of the most modern and best instruments for this purpose 
is the Spencer- Collins portable apparatus, consisting of a nickel- plated 
flat reservoir, five and one-half inches high by four inches long, and one 
and five- eighth inches wide, to the bottom of which is attached a force 
pump with glass barrel surmounted with a metal cylinder, also trocar 
and cannula of metal. The pump is detachable, thus permitting the 
various parts to be carried inside the reservoir, making a neat, compact 
apparatus, all parts of which can be sterilized. When the reservoir 
is filled and the piston of the syringe is pulled out, one-half ounce of the 
fluid passes into the barrel of the syringe, and when the piston is pushed 
in, this amount of fluid is projected through the cannula into the vein. 
A simple glass funnel, tube, trocar, and cannula make a very satisfactory 
apparatus and are preferred by many to the more elaborate outfit. After 
thorough sterilization of the skin, the forearm is partially supinated, 
and an incision one to two inches' long is made over the median basilic 
vein, through the skin and superficial fascia. With a blunt instrument 
the adipose tissue is torn through and the vein exposed, and lifted from 
its bed ; two catgut ligatures are carried under the vein and one is drawn 
toward the distal extremity of the wound and tied securely, thus ligating 
the vein in continuity. The other ligature is drawn toward the proximal 
extremity of the wound, and one knot is loosely tied; with a delicate 
pair of thumb forceps grasp the periphery of the vein and with a sharp 
pair of curved scissors cut half-way through the diameter of the vein 
transversely, immediately under the bite of the forceps. This makes 
a free opening into the vein, guarded by a flap in the grasp of the forceps. 
The blood now runs out freely, and would obscure the opening but for 
the grasp of the forceps. Lifting the little flap with the forceps in one 



n6 



POSTOPERATIVE TREATMENT. 



hand, the cannula, with the fluid running to prevent any air entering the 
vein, is thrust quickly into the opening; the ligature which was only 
lightly tied is now tied down on the vein and cannula, which thus pre- 
vents leakage of the fluid from the vein. When the cannula is with- 
drawn, this ligature is simply tied firmly down, closing the vein perma- 
nently. That part of the vein between the two ligatures may be excised 




Fig. io. — Hypodermatoclysis. 

or let alone. The skin incision is closed with sutures and an aseptic 
dressing applied to the part. 

The quantity of saline fluid to be injected varies according to age, 
the amount of fluid lost in cases of hemorrhage, and the reaction signs 
inr,cases of shock or collapse. In cases in which there has been marked 



ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT. 117 

hemorrhage, the amount should be greater than in simple collapse or 
shock. The quantity ranges from a few ounces to two or three quarts. 
The chief guide in all cases is the return of the pulse, with increase 
in volume and diminution in rate, and the return of color, facial expres- 
sion, and consciousness. 

Locke's solution with or without adrenalin is preferable. The 
temperature of the solution should be kept at no° F. The fluid should 
flow in very gently, and a second injection is rarely necessary, although 
in cases of prolonged shock or sepsis the injections may be repeated 
every four to six hours. 

Rectal Alimentation. — After many operations rectal feeding is 
of such importance that the attending surgeon should be thoroughly 
conversant with the subject. There is a wide difference of opinion as 
to what constitutes the best preparation or most easily assimilated 
foods for this purpose. So many formulas have been advanced that 
are absolutely inert, if not harmful, that I have deemed it best to give 
in detail what we have found from actual experience to be the most 
valuable and useful. There are certain foods which the rectum assimi- 
lates, and others which it rejects. Starches, oils, and fats should not be 
given, for the bowel is intolerant of them, and oils and fats, by coating 
the mucous membrane, prevent the absorption of nutrient material 
much in the same way that mucus does. 

J. N. Jerome ("Int. Med. Jour."), in an article upon this subject, 
emphasizes certain points as essential: 

"1. The quantity and quality of food should be so regulated as to 
avoid exciting peristalsis, and also that the first injection should be 
entirely absorbed before another is given. 

"2. The irritation, if any, of the bowel should be allayed. Some- 
times in extreme irritability opium may have to be used, but it is 
well to avoid it, if possible. While opium checks peristalsis and favors 
the retention of the enema, yet it also, to a certain extent, inhibits the 
absorption of the nutrient material. 

"3. The rectum should be cleansed of all mucus, feces, and foreign 
matter." 

The author insists upon great care as to detail, since carelessness 
may produce rectal irritation and intolerance of food. When properly 
given, although the enemas may not be retained the first day or two. 
the proper nutrition can soon be administered in this manner. It can 
seldom, however, be given a long time without producing diarrheas, 



1 1.8 POSTOPERATIVE TREATMENT. 

and in these cases it is well to withhold the enemas until the irritation 
has subsided. 

"Hemorrhoids are a severe stumbling-block in successfully using 
this method, but their presence is not a positive contraindication. In 
these cases only the softest rubber catheter should be used and local 
anesthesia of piles established by the topical application of a 2 percent 
solution of cocain. 

"When the enemas are long continued it is well to wash out the 
rectum at least once a day with warm water, soapsuds, or boric-acid 
solution. By this means all foreign matter is removed, feces are dis- 
lodged, and mucus and any remains of a former injection washed 
away. It is very important to use only those articles of food which 
are completely absorbed. All other material acts as a foreign body 
and causes irritation of the rectum." 

The best forms of food to employ are among the following: 

"Milk. — This is universally used. It should not be too rich, for 
the fat in the cream is not absorbed, and prevents the absorption of 
the milk proper. It is well, sometimes, to use predigested milk, and 
thus save the rectum a certain amount of labor. 

"Eggs. — The white of egg is one of the best ingredients of enemas. 
The yolk should not be used, for it is too rich in fats. It is preferable 
that the eggs be partially predigested by the addition of a peptogenic 
or pancreatinizing powder. This may be added to the peptonized 
milk or to a peptone solution of meat extract. A little salt may be 
added to the eggs to promote absorption, but it is sometimes irritating 
to the rectum. 

"Alcohol. — Used for rectal injections should be of the best and 
purest kind. Rum, brandy, or sherry wine may be used, but a good 
whisky is by far preferable. It can be used in connection with the 
other rectal foods, but if too strong may precipitate the curds in the 
milk. 

"Meat Extract. — A peptone solution of meat extract may also 
be used alone or in combination with any of the foods above enumerated. 

" Defibrinated Beef-blood. — This also is used to some extent. 
The beef-blood is prepared by whipping with light switches. The 
only objection to this is the odor which it leaves. 

"All injections should be given at a temperature of from 90 to 
95 F. If colder or warmer, they may excite peristalsis and cause 
rejection of food. The number of injections depends to a great extent 



ADJUNCTS OR AIDS IX POSTOPERAT1VK TREATMENT. 119 

upon the condition of the rectal walls. It is usually advisable to give 
one even- six hours, and then, if retained and absorbed, they can be 
increased to one even- four or three hours." 

In giving an enema, it is well to use only a soft-rubber catheter or 
tube. In the selection of the tube, one should be chosen that is not 
so stir! as to cause injur}' to walls nor so soft as to double upon itself 
if a little force is used. It should be lubricated with sweet oil, vaselin, 
butter, or glycerin. 

"The enema may be given by means of a small hard-rubber syringe, 
or, as I prefer, a fountain syringe. There should be but little force 
exerted and the patient instructed not to strain. The tube should be 
introduced from eight to twelve inches into the bowel. Care should be 
taken that no air enters the bowel, as it excites peristalsis, and this is 
prevented by filling the tube with enema just before it is introduced." 

There are many special preparations on the market especially recom- 
mended for this purpose, but these are not so uniformly successful. 
Among those which are often employed are peptonoids, panopeptone, 
somatose, and liquo-peptone, various beef-juices, and other similar 
preparations. 

The following formulas are used in the Philadelphia Hospital: 

1. Beef-tea, 3 ounces. 3. Beef essence, 6 ounces. 

Yolk of one egg, Whites of two raw eggs, 

Brandy, § ounce. Peptonized milk, 2 ounces. 

Liquor pancreaticus, 2 drams. Two eggs. 

2. Beef-tea 2 ounces. 4. Whites of three eggs, 

Brandy, h ounce. Ox serum, 4 ounces. 

Cream, h " Starch, raw, 1 ounce. 

Salt, 1 dram. 

Normal Salt Solution. — Many modern surgeons rely solely upon 
normal salt solution. Ochsner prefers one ounce of liquid peptonoids 
and three ounces of normal salt solution given every three to four hours 
by attaching an ordinary glass syringe (piston removed) to a Xo. 8 or 10 
soft-rubber catheter. Insert the catheter two or three inches and pour 
the food into the glass syringe, which takes the place of a funnel, and let 
it enter the rectum by its own weight. 

We have followed this plan in several instances with the greatest 
satisfaction. To give nutrient injections successfully, the solution to be 
used must be at a temperature of ioo° F. It should be introduced very 
slowly and carried very gently as far into the bowel as possible. In 



120 POSTOPERATIVE TREATMENT. 

many instances a high enema tube is preferred to the catheter. The 
quantity ordinarily employed should not exceed four ounces. To 
lubricate these tubes sterile olive oil only should be used. 

To facilitate retention a small folded napkin is wet with cold water, 
and placed directly against the anus and held for a few minutes; this 
will usually overcome any tendency toward tenesmus. The bowels 
should be cleansed at least each day by copious but gentle enemas 
of normal salt solution. 

Subcutaneous Feeding. — When forced feeding is necessary, and 
when no nourishment can be taken by the stomach, and especially when 
there is rapid emaciation from want of nourishment, and frequently 
if the rectum has become so irritable that enemas cannot be retained, 
one to two ounces of sterilized olive oil may be injected into the sub- 
cutaneous tissue of the groin. The oil must be introduced very slowly, 
and should not be repeated more than once in twenty-four hours. A 10 
percent solution of grape-sugar has been highly extolled by English 
surgeons for this purpose, but seems to cause considerable irritation at 
the site of the injection. 

Inunctions. — A certain amount of nutritious matter can be intro- 
duced into the body by inunctions. The skin must be prepared by 
means of sponging with soap and water and by frequent light massage. 
The materials usually employed are sterile olive oil, or cod-liver oil two 
parts and alcohol one part. George Boody has used with success leaf- 
lard inunctions applied thoroughly twice daily to the chest, abdomen, 
and back. The patient's strength is undoubtedly increased by such 
treatment. 

Bandaging. — "The object of bandages is not only to hold in place 
surgical dressings and splints, but they are frequently employed to 
exert pressure on certain parts, control hemorrhage, relieve congestion, 
promote absorption of extravasated liquids or exudates, to prevent 
edema, support circulation, weaken vessels, correct deformities, as well 
as to give protection and support to injured limbs and joints." (Brewer.) 

Bandages are made of gauze, flannel, cotton, linen, india-rubber, and 
unbleached muslin. They vary in width and length. According to 
Warton and Curtis, bandages for the hands, fingers, and toes should 
be one inch wide and three yards long; for the extremities in children, 
two inches wide and three yards long; for the extremities in adults, two 
and a half inches wide and seven yards long; head-bandages, two inches 
wide and six yards long; thigh and groin bandages, three inches wide 



ADJUNCTS OR AIDS IX POSTOPERATIY1 TREATMENT. 121 

and nine yards long; trunk bandages, four inches wide and ten 
yards long. For ordinary purposes the best material for bandages is 
unbleached muslin, which is first washed in sodium carbonate solution 
to remove the sizing, and is then torn in strips of the desired width and 
length. The selvage is removed and the strip is made into a roll. 

In postoperative work, when employed for the purpose of retaining 
dressings, the application of the bandage may be begun at any part of 
the limb below the wound, and the bandage is then carried to the point 
where the dressings are to be covered. After such a bandage has been 
applied, if the patient complains of too much constriction, the first 
turns should be cut with scissors. If a bandage is to be used to make 
pressure on any portion of a limb, its application should be begun at 
the fingers or toes, and the bandage should be carried up to the place 
where the pressure is needed. " Compression should not be made in 
the middle of a limb by a tightly applied bandage without having first 
included the fingers or toes, as such a procedure would produce pain, 
swelling, and edema, and, if prolonged, might cause gangrene." (Hare.) 

Bandages to Give Support and Make Compression. — If we are 
dealing with a condition which is in need of support and compression, 
such as a slight sprain, a swollen joint, varicose veins of the leg, or 
ezcematous ulcers of the lower extremities, bandages, made of some 
elastic material should be used, such as flannel cut on the bias, elastic 
webbing, or india-rubber. There are two forms of india-rubber ban- 
dage which have special names: one which is very thin, and made of 
rubber similar to that employed in making rubber dam, is known as 
Martin's bandage, and another, made of web-elastic and known as 
Randolph's bandage. They may be used for practically the same 
purposes. Martin's bandage is used in the palliative treatment of 
varicose veins of the leg. Its application may cure an ulcer of the leg 
caused by varicose veins, but it would best be used as a prophylactic 
measure in varicose conditions, or worn to prevent a recurrence of the 
leg ulcer once it is cured. This bandage when applied will give an 
elastic support which will have a tendency to turn a flow of venous 
blood from the superficial veins into the deep veins. In this condition 
the Martin bandage should be applied while the leg is slightly elevated 
and before the patient arises in the morning; it should not be removed 
until he has retired at night, and after it has been removed it should be 
washed with soap and water, dried, and hung up until morning. 

When it is desired to make pressure or support, in case of sprain, 



122 



POSTOPERATIVE TREATMENT. 



varicose veins, effusions, etc., the flannel bandage is most useful when 
cut bias and made of sufficient length, as it is then much more elastic 
than when cut straight. 

Methods of Applying the Roller Bandage. — If the part to be 
bandaged is of even size throughout, as the upper arm or trunk, the free 
end of the bandage is laid upon the part and held in place by thejeft 




Fig. ii. — Spiral Reversed Bandage Applied to Forearm. 




Fig. 12. — Spiral Reversed Bandage Applied to Leg. 

hand, while the roller is carried by the right hand around the part to be 
bandaged in such a way that the second turn will hold the first firmly 
in place. Each revolution of the bandage covers at least one-half of 
the last turn. When the upper limit of the bandage is reached, the 
end is pinned to the layer beneath. If the part to be bandagedlis 
conical, as the leg or forearm, the spiral reversed bandage is applied, in 



ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT. 1 23 

which each turn is made to fit snugly to the limb by being turned upon 
itself, as seen in Figs, n and 12 ;or the figure-of-eight bandage is employed 
in which the lower loops of bandage are snugly and evenly adapted to 
the limb, and as the bandage ascends they eventually cover the more 
loosely applied upper loops. On the leg this is by far the better bandage 
for ambulatory patients. Properly applied, it will remain in position 
for days; the spiral reverse 
is prone to loosen and slip 
down (Fig. 13). In apply- 
ing a bandage to the groin 
or shoulder, the spica is em- 
ployed, beginning on the 
limb and making a figure- 
of-eight around the limb 
and trunk, as seen in Fig. 14. 
In bandaging the groin, 
however, especially in am- 
bulatory patients, this band 
age will remain in position 
much better if a few turns 
are carried directly around 
the waist (Fig. 15). 

In bandaging the thumb 
or one of the fingers, the 
free extremity is covered 
with the spiral reversed; 
and when the base is reached 
the spica is used, the upper 

loop of which encircles the 

. Fig. 13. — Figure-of-Eight Reversed Bandage 

digit and the lower loop the Applied to Leg. 

hand and wrist (Fig. 16). 

In bandaging the knee, the figure-of-eight is used, the first turn being 

taken around the joint opposite the middle of the patella, after w r hich 

the loops alternate, one being applied above and the next below the first 

turn (Fig. 17). In bandaging the head, one or two loops are made 

to encircle the head, passing from the frontal region just above the eyes 

around the occipital protuberance; the bandage is then applied in a 

transverse direction, beginning just above one ear and carrying the first 

turn over the center of the vault to the opposite ear; then a number of 




124 



POSTOPERATIVE TREATMENT. 



turns are taken between these two points alternately in front of and 
behind the first until the entire vault is covered. The loops made by 
reversing the bandage just above each ear are firmly held until all the 




Fig. 14. — Spica Bandage Applied to Left Shoulder. 




Fig. 15. — Single Spica Bandage Encircling the Waist. — {After Bassini.) 



transverse turns are made, and finally secured by three or four encircling 
turns around the forehead and occiput, safety-pins being finally intro- 



ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT. 



125 



duced to hold all in place (Fig. 18). The folds covering the vault 
may also be made longitudinally if desired (Fig. 19). 




Fig. 16. — Spica Bandage Applied to Finger with Loop of Hand and Wrist. 




Fig. 17. — Proper Method of Applying Bandage to Knee. 



In bandaging an amputation-stump, make one or two circular turns 
around the circumference of the stump, then a number of recurrent 



126 



POSTOPERATIVE TREATMENT. 



turns at a right angle to these, inclosing the extremity, and holding these 
in place by a circular or reversed spiral from the extremity upward 
until a joint or some bony protuberance is covered to hold it in place. 

The Modified Velpeau JBand- 
age for Holding the Arm Se- 
curely to the Chest-wall. — 
Place the hand of the injured side 
on the opposite shoulder; take two 



ESP 






■~ x/ i 



% 



Fig. i 8. 



■Gibson's Bandage. 
-(Wharton.) 



Fig. 



19. — Modified Barton's Bandage. 
— (Wharton.) 



or three turns of a wide roller bandage around the thorax, including 
the arm; then pass the bandage from the free axilla behind to the 
fixed shoulder, passing over this shoulder from behind forward; carry 

the bandage around the point of the 
elbow and then upward behind the 
same shoulder over its summit down- 
ward in front to the free axilla, then 
circularly around the chest, alternat- 
ing these turns until the entire arm 
and chest are included (Fig. 20). 
All these methods may be modified 
to meet special indications. 

The triangular or folded hand- 
kerchief bandage is made by folding 
a square piece of muslin or gauze 
into a triangle. This can be applied 

Fig. 20.— Spica Bandage Applied over a bulky dressing of the hand 
for Operations on Shoulder . . . . . 

or Clavicle. or amputation-stump by placing the 




ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT. 



127 



base of the triangle at a right angle to the limb and folding the apex 
over its extremity, and securing it by wrapping the two extremities of 
the base snugly around the limb and tying them. This bandage may 
also be employed on the head. 

The T-bandage is used for dressings applied to the perineum, the 
horizontal arm encircling the trunk, the perpendicular arm passing 
between the thighs from behind upward and fastened to the front of the 
body portion. 

The Elizabeth Trotter many-tailed abdominal bandage, as 
recommended by Brockman, 
is applied as follows: Unroll 
the bandage enough so the 
middle strip will come just 
under spine and parallel with 
it, then let each end drop over 
the side of the table as it un- 
rolls. Begin at the top on one 
side and bring the upper tail 
across body at a slight angle 
with the body, then bring the 
top one from the opposite side 
over and across it at same 
angle. 

Then proceed the same with 
each succeeding pair of tails 
till they are all on. One or 
two safety-pins will fasten the 
last ones and they will bind or 
hold in position all the rest of 
the bandage. The advantage 
of this form of bandage is that it will fit any form of abdomen and fit 
it perfectly. 

The many-tailed bandage is useful for almost any part where dressings 
are frequently changed. It is particularly serviceable when a firm 
abdominal binder is required and in breast amputations. 

The two-tailed jaw bandage is useful for holding the lower jaw 
firmly against the upper, as in fractures of the lower jaw or in wounds 
of the chin. 

The sling, to support the forearm and arm, is made by folding 




Fig. 21. — Sodium Silicate Dressing. — {Hare.) 



128 



POSTOPERATIVE TREATMENT. 



a large piece of muslin into a triangle. Place the two extremities of 
the base-line around the neck and allow the forearm to rest in the loop. 
The Sling and Chest-binder. — This is a very useful bandage for 
fixing the arm to the chest, and is used in fractures of the clavicle and 
humerus, injuries to the shoulder and elbow. Place one extremity 
of a triangular sling in place around the neck, flex the elbow, and place 
the forearm across the chest; then apply a chest-binder including the 
upper arm, and fix with safety-pins, after which the other extremity 
of the sling is folded around the forearm and carried upward around the 




Fig. 22. — The Many-tailed Abdominal Bandage. 



neck and tied to the one already in place; fasten all these layers together 
with safety-pins. 

Adjuncts to Postoperative Treatment. — Of the many modern 
appliances invented for the comfort and management of patients, we 
can refer to but few, and that briefly. Many of these inventions are 
not perhaps actually necessary, yet they prove of value in so much that 
they contribute materially not only to the comfort of the patient, but 
simplify and facilitate the after-care, and should therefore be obtained 
when possible. 

The fracture-bed, especially for use after compound fractures, is 
now almost indispensable. There are several varieties or patterns, all 



ADJUNCTS OR ADDS IN POSTOPERATIVE TREATMENT. 



129 



of which have proved exceedingly useful. Fig. 23 illustrates Munger's 
invalid or fracture-bed. Fig. 24 illustrates the mechanical adjustment. 




Fig. 23. — Munger's Invalid Bed. With Mattress Raised to Semi-sitting Pos- 
ture and Bedpan in Place for Use. 




Fig. 24. — Munger's Invalid Bed. 



The mechanism of the fracture-bed permits elevation of the head and 
trunk to a sitting position without disturbing the fracture. To the 
9 



i3° 



POSTOPERATIVE TREATMENT. 



seat-board are attached two limb supports, each working independent, 
and so situated that one or both of the lower limbs may be placed at 
any desired height without regard to the position of the patient's trunk. 




Fig. 25. — Crosby's Invalid Bed. 



A longitudinal central slit in the hair mattress permits the introduction 
of a bedpan, and thus avoids lifting or elevating the hips. 

The Crosby invalid bed, which is popular in some hospitals, is 

illustrated by Fig. 25. 
The "Michael 
Reese hospital 
lifter" is shown by 
Fig. 26. It is of 
great utility in the 
treatment of various 

w l complications. This 

{a EV^te^L /K device is indicated for 

/ VS^T"^ J x use in cases in which 

it is desired to raise 
helpless patients from 
a bed. 

The apparatus is 

well shown in the 

illustration, and is of 

such construction that 

by means of a crank and geared mechanism a patient of any weight 

may be lifted either for the purpose of rest or transfer to another bed. 




Fig. 26. — Lifter for Raising or Lowering Patient. 



ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT. 131 




Fig. 27. — Janeway Bed Lift. 




Fig. 28. — Janeway Bed Lift. 



132 



POSTOPERATIVE TREATMENT. 



The Jake way bed lift — (Dr. H. H. Janeway, New Brunswick, 
N. J.) is a more recent invention and is constructed in such a manner 
as to be easily placed together, or taken down, hence portable, and of 
special use in private practice. For hospital use the 
upper pillars may be attached by means of screw plates 
to the floor, thus dispensing with the heavy floor of cross 
beam. The mechanism is very simple, the apparatus 
strong and durable, and, lastly, very moderate in price. 
Sick- bed Chair. — Among the recent inventions of 





Fig. 29. — Moore's Sick-bed Chair. 




4EKNY-S 



Fig. 30. — Moore's Bed Chair — Patient en Reclining Position. 



ADJUNCTS OR AIDS IN POSTOPERATIVE TREATMENT. 



133 



great utility is that of Moore's sick-bed chair. By its use but one 
attendant is required, and the patient can be handled with ease and 
comfort. The following cuts, Figs. 29, 30, and 31, illustrate the method 
and manner of usage. It is not only useful, but is highly appreciated 
by patients, owing to its simplicity and efficiency. 

It is made of light wood and folds into a compact form, and by ele- 
vating slightly or turning the patient partly upon the side can be easily 




•"CHfEftfR CO..VY 



Fig. 31. — Moore's Bed Chair — Patient in Erect Position. 



placed into position. The patient may then be elevated to the sitting 
position if necessary, with little exertion on the part of the attendant. 
The illustrations explain the apparatus more fully than any lengthy 
description would. 

The medico-mechanical massage apparatus, as illustrated in 
Figs. 32, 33, and 34, is a very valuable adjunct in the after-treatment 
of dislocations and fractures, for the correction of joint motion or muscu- 



ZA 



POSTOPERATIVE TREATMENT. 




Fig. 32. — Medico-mechanical Apparatus. 




jt ig . 33 . — Medico-mechanical Apparatus, as Applied eor Ankylosis of the 

Knee. 



ADJUNCTS OR AIDS IN POSTOPKRA II VK TRKATMENT. 



135 



lar impairment. This apparatus is used in many of the European 
elinics. It is so constructed as to allow natural movements of the various 
joints and muscles, and is regulated by weights or counterbalances. 
These may be so graduated as to conform to the amount of action or 
motion of any joint or muscle; for instance, with a patient suffering from 
partial ankylosis of the knee with only a slight movement of the joint, 
the apparatus is so adjusted to the limb to suit the requirements of the 
case, and so that the limb can be carried but little beyond the point of 
resistance. Continued use gradually increases the action of the joint 




Fig. 34. — Medico-mechanical Apparatus, Adjusted for^ Ankylosis of the Elbow. 



movement, finally effecting complete restoration. The great value of 
the apparatus lies in the fact that the treatment on the part of the patient 
is self-induced. The cuts fully illustrate the method of application of 
its various attachments. 



CHAPTER VII. 
HEALING OF GRANULATING WOUNDS. 



CHAPTER VII. 
HEALING OF GRANULATING WOUNDS. 

Healing of Granulating Surfaces. — The process of repair upon gran- 
ulating surfaces, the manner through which healing is produced, and the 
best means needful for local treatment, is still an open question, as shown 
by the different methods employed by surgeons at the present time. All 
agree that physiologic rest is the essential feature in the treatment ; i.e., 
complete repose, obtained through the application of proper splints, 
confinement in bed when necessary, and, lastly, the aseptic and antisep- 
tic protection of the granulating surfaces. In the healthy or normally 
healing surfaces but little treatment is necessary, except protection of the 
surfaces, prevention of external irritation, etc. When temporary slough- 
ing or unhealthy healing becomes manifest, various stimulating agencies, 
such as silver nitrate, zinc chlorid, and balsam of Peru are applied to 
stimulate or spur sluggish granulation. Aqueous solutions, if mild and 
nontoxic, permit easy and efficient washing of the surfaces. Balsamic 
preparations are of use in specific forms of ulcers. The dressing which 
adapts itself most perfectly to the factor of rest and asepsis is the best 
possible treatment for acute granulating wound-surfaces. (Kocher.) 

To subject the surfaces of granulated wounds to the action of chem- 
ical irritants, hydrogen dioxid, mercuric chlorid, carbolic, acid, etc., is 
harmful rather than useful, owing to their tendency to destroy the delicate 
granulations and new epithelium. The skilful management of granu- 
lating wounds requires long training and a knowledge of the pathology 
of repair. As a stimulant to unhealthy granulating surfaces, the use of 
gold-beater's skin, as suggested and prepared by Outten, of St. Louis, 
has proved of such great value in our hands in prolonged aggravating or 
unhealthy granulating surfaces that I give herewith his method in detail : 

"Large and perfectly cleaned sheets of gold-beater's skin are selected. 
The sheets are put in hot sterilized (not boiling) water, sufficiently hot 
not to interfere with the texture of the skin, from 98 to ioo° F. — a stream 
of hot water preferred. After having remained in the hot water suffi- 
ciently long to cleanse them, they are then taken therefrom, and squeezed 

139 



I4-0 POSTOPERATIVE TREATMENT. 

as free from water as possible. A solution is now ready, made of the 
following agents: 

Cobalt chlorid, i ounce. 

Gold chlorid, i dram. 

Distilled water, 10 drams. 

The skins are now put in this solution so that it entirely covers the skin 
in any container that may be used. After the skins have been put in 
the container holding the gold- cobalt solution, two ounces of the oil 
of cinnamon is poured in on the skins now immersed in the gold- cobalt 
solution. 

"The sheets of gold-beater's skin thus prepared are kept in a wide- 
mouthed, glass-stoppered container, immersed in the chemical solution 
of oil of cinnamon, as above mentioned. When the membranes are 
used upon a granulating surface, the following is the method indulged 
in : A piece of the treated membrane of sufficient size to well cover the 
entire granulating surface is cut. This piece is applied to the granulating 
surface after the following course is pursued. It is put in alcohol and 
allowed to stay in the alcohol from three-quarters of an hour to an hour. 
It is then taken out of the alcohol and put into hot water from 98 to 
ioo° F. The membrane is put in the alcohol for the purpose of remov- 
ing any excess of the oil of cinnamon, thus preventing heat and pain 
likely to come from the irritating stimulation of the cinnamon oil. After 
the membrane has remained in alcohol sufficiently long, and then put 
into the water to remove the excess of alcohol, the skin is dried by putting 
it between the layers of a sterilized towel or cloth. A few punctures 
are made through the membrane, which is now applied to the granulating 
surface. The membrane thus applied is now covered with six or eight 
layers of sterilized gauze. Another piece of membrane is then applied on 
top of the gauze large enough to strain the air in its access to the wound. 
The membrane thus applied on the sterilized gauze need not be put in 
the alcohol, but simply squeezed between the folds of a cloth to remove 
the excess of the solution contained on the membrane. Now there is 
put on this membrane a layer of sterilized cotton, and then a retaining 
bandage is applied. It is thus seen that a needed and well-timed dis- 
cipline is here indulged in for the application of the gold-cobalt membrane. 
The dressing thus applied to the granulating surface is allowed to remain 
intact for at least forty- eight hours. 

"After the first application of the gold-cobalt membrane to granu- 
lations they assume a bright, vivid, healthy hue (bright as blood can 



HEALING OF GRANULATING WOUNDS. 141 

make them), looking firm, erect, even, and healthy. Besides this, the 
epithelial border appears to be stimulated in a remarkable manner. 
It is readily demonstrable that after the application of the gold-cobalt 
membrane a minimum amount of interference with the granulating sur- 
face is obtained. There is no necessity of friction in cleansing the 
surface, as when unguents are used. The lightest touching of the granu- 
lating surface when cleansing seems to be sufficient. 

"As an aid in the perfect establishment of skin-graft it is an ideal 
method, whether we use it in the Reverdin or Thiersch method. In the 
Thiersch method, when used with the membrane, every graft appears to 
live and flourish. When the Thiersch method is used, the granulating 
wound-surfaces and grafts are prepared with the saline solution, as is 
usually done. The gold-cobalt membrane is put in alcohol the same as 
in the treatment of granulating wounds. It is washed out with hot 
water, and then put into the normal saline solution until it is thoroughly 
soaked and permeated. After the grafts have been applied to the granu- 
lating surface, from one to four perforated gold-cobalt membranes are 
applied. I generally apply two membranes, and after forty-eight hours, 
upon examination, the grafts will be found in a healthy condition and 
adherent to the granulation. The salt-water gold-cobalt membrane 
is again applied for another forty-eight hours. After this time the regu- 
lar alcohol-treated membrane surface may be applied. When these 
grafts are applied upon a fresh curetted surface with treated membranes 
in position, great impetus to the healing process is manifest. " 

SKIN-GRAFTING.* 

When the removal or destruction of integument has been so extensive 
that cicatrization cannot be effected on account of the tension of the parts 
involved, skin-grafting should be practised. There are three recognized 
methods — grafting, sliding, and transplantation in mass. Sliding and 
transplantation in mass are usually performed at the time of the opera- 
tion. As skin-grafting, however, is frequently a postoperative measure, 
the ordinary technic is described in detail. There are two recognized 
methods of skin-grafting, known as Reverdin's "epidermis-grafting" and 
Thiersch's "skin-grafting." 

In Reverdin's method small thin portions of the superficial layer 
of the skin are snipped off with curved scissors. Pieces about the size 

* Abstract from Cheyne's "Manual of Surgical Treatment," Lea Bros. & Co. 



142 POSTOPERATIVE TREATMENT. 

of a hempseed are planted on the surface of the granulations at short 
distances from each other; epidermic growth occurs from each of these 
little points, and the result is that numerous small islands of epithelium 
form over the surface of the sore. If the grafts are close enough together 
and the other conditions of healing are favorable, these islands of epider- 
mic growth soon coalesce, and in this way rapid cicatrization is obtained. 
It is necessary that these grafts should not be too far apart, because, as a 
rule, they have only a limited power of reproduction. Usually each 
graft gives rise to an island of epidermis about the size of a sixpence, and 
then growth seems to come to a standstill. The result of this method of 
epidermis-grafting is that rapid healing is obtained in many cases, more 
especialy in burns and sores on the trunk, where the skin is freely mov- 
able over the deeper parts. Further, the contraction of the subsequent 
cicatrix is considerably diminished, because less granulation tissue is 
formed than if the sore has to heal altogether from the margin, and the 
amount of contraction depends entirely on the amount of young granula- 
tion tissue produced. Nevertheless, a considerable amount of contrac- 
tion will inevitably occur when healing has been obtained in this way, 
and the resulting scar is not materially stronger than that obtained by 
permitting the sore to heal from the edge. 

Thiersch's Method. — With a view to obtaining a sounder scar, much 
more extensive and thicker portions of the skin must be taken, and the 
grafts must be applied close together. This is known as Thiersch's 
method. In this method the skin which is to be used for the grafting 
must first be thoroughly disinfected in the usual manner, namely, by 
turpentine, soap, and strong mixture, and it must also be carefully 
shaved. The presence of hairs on the grafts seems to interfere materi- 
ally with their union. The skin of the front of the thigh or the flexor 
surface of the forearm is usually employed for the purpose. 

Preparation of Wound. — (a) Preliminary. — The wound itself 
must also be prepared beforehand. It is of no use to graft a wound 
which is actually ulcerating ; it must be brought into a healthy condition, 
and healing must have commenced before grafting is likely to be success- 
ful. The best criterion that healing is taking place is the presence at the 
edges of the dry red line which indicates recently formed epithelium. 
Some surgeons wait for a considerably longer time before grafting, in 
order to get a firm layer of granulations, but our experience is that, so 
soon as healing begins around the edge, the wound may be safely grafted 
upon. A second essential is that the wound shall be aseptic. If it is 



SEALING OF GRANULATING WOl'XDS. 143 

suppurating, and the discharges - ptic, the graft — which is, after all, 
merely a piece of dying tissue — will become impregnated with decompos- 
ing pus, and will rapidly become loosened, die, and undergo decompo- 
sition. The methods of rendering the wound aseptic have already been 
described. 

(b) Operative. — With a wound that is aseptic and beginning to 
heal, the following is the method of procedure : The patient having been 
put under an anesthetic, the granulations over the whole surface of the 
wound are evenly scraped away, taking care, however, to remove only 
the soft layer of granulations and not to go through the deeper one of 
newly formed fibrous tissue into the fat. A surface is thus left which is 
smooth, highly vascular, and firm, and consists of the deeper layers of 
granulation tissue which have already become organized into fibrous 
tissue. One is tempted to limit the skin-grafting to the parts actually 
unhealed, but if this is done the result will, as a rule, be very disappoint- 
ing, for. while the part that has been grafted remains perfectly sound, 
the margin where spontaneous healing has occurred is very likely to 
break down, and thus a narrow line of ulceration appears later on at the 
site of the edge of the wound. Having then removed the layer of granu- 
lations in the manner described, and cut away the newly healed edge of 
the wound, the next thing is to arrest the bleeding completely before 
applying the grafts. This is best done by pressure, but if pressure is 
applied directly to the sore either by sponges or dressings, it will be found 
that the bleeding begins again when they are removed, because they 
stick to the raw surface. The best plan is to interpose a piece of protec- 
tive sterilized oiled silk covered with a layer of dextrin, which prevents 
adhesion of the sponges to the sore and thus avoids a renewal of the 
bleeding on removal. Hence, when the scraping and cutting are finished, 
any spouting vessel is clamped, and a large piece of protective dipped 
in the 1 : 2000 mercuric chlorid solution is applied over the raw surface. 
Outside of this several sponges are placed, and a bandage dipped in 
1 : 2000 mercuric chlorid solution is firmly bound over them, or if the 
wound is small and an assistant available, he may apply the pressure. 

Cutting the Grafts. — While the bleeding is being arrested by pres- 
sure, the surgeon proceeds to cut his skin-grafts. In Thiersch's method 
the grafts may be taken from any part of the body, but as a rule, they 
are most conveniently cut from the front of the thigh. The skin having 
been disinfected, the surgeon grasps the thigh from behind with his left 
hand, keeping the skin as tense as possible, and also making it prominent 



144 POSTOPERATIVE TREATMENT. 

and flat by pushing the muscles and skin forward from the bone. The 
skin is further put on the stretch vertically by an assistant who pulls 
it upward at the groin and downward at the knee. The razor, which 
should have a very broad blade, is dipped in boric acid lotion or normal 
salt solution, and is constantly kept wet by this solution while the grafts 
are being cut, just as in making microscopic sections of fresh tissue. If 
this irrigation is not maintained, the graft tends to adhere to the razor 
and may be either partially or wholly cut through before a sufficient 
length has been obtained. The razor is made to penetrate through 
about half the thickness of the skin, and then, by a lateral sawing motion, 
the grafts are cut as broad and as long as possible. After a little practice 
it is easy to cut grafts about two inches in breadth and six or seven inches 
in length. If one graft is not sufficient, it is best simply to slide it off 
the razor and leave it lying on the bleeding surface; in this way it is 
kept warm and moist. Some surgeons put the graft into warm normal 
salt solution or saturated boric-acid lotion, and it is then said to spread 
out more easily afterward, but by the former plan the tissues He in their 
own juices and the cells are more likely to retain their full activity. 

Application of Grafts. — When a sufficient number of grafts have 
been cut, the bandage, sponges, and protective are removed from the 
wound, and if bleeding has quite stopped, as is generally the case, the 
grafts are applied to its surface. The latter usually has a thin layer of 
blood-clot upon it, and this should be gently wiped away. Each graft 
is lifted with forceps or the fingers, and placed on the sore with the cut 
surfaces downward, and then, by means of a couple of probes, the folds 
of the graft are carefully undone, and it is stretched evenly over the sur- 
face. The grafts should overlap the edges of the skin and also each 
other, so that no part of the raw surface is left exposed, for granulations 
always spring up on the uncovered parts, and are apt to eat away the 
grafts in their vicinity; furthermore, a thin scar, which may subse- 
quently break down, is left at these points. The graft is always thinner 
at the edge than at the center, and it is these thin edges which overlap 
each other or the edge of the ulcer; there is no real sloughing of these 
overlapping edges. 

Dressings. — In spreading out the graft it will be found that air-bubbles 
collect beneath it, and also that some amount of oozing goes on, and the 
bubbles and clot may prevent complete adhesion of the graft. Hence 
the next procedure is to get rid of them by pressure. If that is attempted 
by means of sponges or the hands, the graft is apt to be displaced. The 



HEALING OF GRANULATING WOUNDS. 1 45 

following is the best plan : Strips of protective about an inch in breadth 
and long enough to overlap the edges of the wound, purified in i : 20 car- 
bolic lotion and subsequently rinsed in boric acid lotion, are applied 
firmly over the grafted surface, beginning at the lower part. Each strip 
should overlap the one below, just as in the case of strapping, and they 
should extend well on to the skin at each end. If each strip as it is put 
on is grasped by the two ends and firmly pressed down on the limb, 
the pressure thus applied suffices both to expel the air-bubbles and 
blood, and also to arrest further capillary oozing. The whole sur- 
face of the skin-grafts being thus covered, ordinary sterile gauze wrung 
out of 1 : 6000 mercuric chlorid solution is applied, with salicylic wool 
outside it. The limb should afterward be placed upon a splint, or at any 
rate fixed that movement cannot occur during the progress of healing. 

The place from which the grafts have been taken may also be dressed 
with the protective and gauze dressing, which need not be disturbed for 
ten days or a fortnight. At the end of that time the whole surface will 
usually be healed, unless the razor has somewhere gone a little deeper 
than is necessary. If healing is not quite complete, weak boric oint- 
ment may be applied. The limb from which the grafts are taken should 
always, if possible, be the same as that on which is the ulcer requiring 
grafting; for example, when the ulcer is on the leg, the grafts should be 
taken from the thigh of the same side. Unless this is done, a second 
splint will be required to fix the limb from which the grafts have been 
taken until healing is complete. 

Changing First Dressing. — The dressing should be left on the grafted 
surface for about five days; in some cases it may even be left for a week. 
If the wound is aseptic, no suppuration or decomposition takes place 
beneath it. While removing the dressing, it should be thoroughly soaked 
with a 1 : 2000 mercuric chlorid solution, for the protective may stick 
at the edge and adhere to a graft, which may thus be peeled off unless 
great care is taken. The parts should be gently cleansed with a 1 : 2000 
mercuric chlorid solution, and it is best to re-apply the protective and 
gauze dressing for about another week. At the end of that time the 
grafts are fairly firmly adherent, and then a mild antiseptic dressing 
should be applied. 

After-treatment. — It will be found that, even at the first dressing, the 

grafts present a pink color and are adherent to the deeper surface, 

though they are still readily detached. In the course of about a week 

the old epidermis peels off, but no raw surface is left. Later on there is 

10 



146 POSTOPERATIVE TREATMENT. 

great tendency to the formation of new epithelium, cornifications, and 
drying up, and it is in avoiding the latter condition that ointments are so 
useful. In fact, till the scar is absolutely sound it is well to keep the sur- 
face covered with oily application, the best being sterilized cosmolin. 
(Cheyne, "Manual of Surgical Treatment," Lea Bros. & Co.) 

Transplantation in mass is a method not elaborated upon by Cheyne, 
and it appears to have been first used by Wolfe, of Glasgow, and later 
revived by Krause. It consists in removing the entire thickness of the 
skin at a point distant from the granulating surface to be covered. The 
area of the skin-mass must be from one-sixth to one-third larger than the 
granulating surface to be covered, must have been shaved and thoroughly 
disinfected before removal, and contain no particles of subcutaneous fat. 
Sutures are not employed, and the after-treatment is practically the same 
as in the Thiersch method, except that should blebs form on the trans- 
planted skin they are to be opened. Cicatricial contraction is not marked 
after the transplantation method, but the fact that it involves a more 
formidable operation and leaves a large granulating wound where the skin 
was removed detracts from its value as compared with other methods. 

The late A. B. Craig, of Philadelphia, showed ("American Medicine") 
the value of Cargile membrane in skin-grafting, particularly by the Rever- 
din method. He applied the grafts in the ordinary manner, and covered 
the entire field with a sheet of Cargile membrane. Dry sterile dressings 
are placed over this and a firm bandage applied. If the granulating 
surface is old and the skin- edges thickened, strapping is resorted to, the 
adhesive strips being applied over the sterile dressings, and a bandage 
covers the whole. In any event the dressing is carefully removed within 
forty-eight hours, when it will be found that the Cargile membrane is 
largely digested. The advantage ascribed to the use of the membrane 
is that it not only appears to stimulate epithelial growth, but it protects 
the delicate grafts for a number of hours, and is gradually digested by 
the granulations, thus permitting the wound secretions to escape into the 
dressings. This method can be readily carried out on ambulatory pa- 
tients in dispensary servi :e, as well as within the hospital wards. 



CHAPTER VIII. 
OPERATIONS 



CHAPTER VIII. 
OPERATIONS. 

Remarks. — The consideration of the after-treatment of all operations 
would require much repetition, and occupy far more space than can be 
given in this work. I have, therefore, decided to describe only those 
operations which are classed as general surgery, making no attempt 
to invade the field of the specialist. 

Postoperative Treatment of Operations Upon the Scalp, Removal of 
Sebaceous Tumors, Wens, etc. — In operations upon the scalp, removal 
of sebaceous tumors, wens, etc., drainage is imperative. A small piece 
of gauze should be inserted at the most dependent portion of the incision 
and removed on the third or fourth day. The rest of the wound may 
be united and permitted to heal as rapidly as possible. Scalp incisions, 
as a rule, heal rapidly, and owing to the abundant blood-supply, sepsis 
rarely follows. Strict adherence to asepsis and the removal of hair 
well from the field of operation render the after-treatment much easier. 
Dressings should be changed as often as required, and firm bandage 
applied. 

OPERATIONS UPON THE SKULL AND BRAIN. 

General Remarks. — After operations upon the skull or brain the 
patient must be kept quiet in a darkened room. Careful avoidance of 
all excitement and absolute isolation are imperative. The bowels 
should be kept open ; the use of alcohol or other stimulants is contraindi- 
cated. After trephining, the wound is usually treated after the open 
method, i.e., gently packed with aseptic gauze and a compress and 
bandages applied. Should inflammation occur, it is usually manifest 
about three or four days after the operation. Rise of temperature 
and other symptoms of infection call for immediate change of dressing 
and careful irrigation of the wound. If this treatment does not suffice 
and there are indications of further and deeper-seated infection, or if 
abscess of the brain occurs, as manifested by nausea, vomiting, irreg- 
ular chills, with pain in the head (not necessarily in the wound) increased 
by percussion, and especially if there is a tendency to hebetude, normal 

149 



1 50 POSTOPERATIVE TREATMENT. 

or subnormal temperature, disinclination to make effort, and stupor, 
an effort should be made to locate the abscess and evacuate the pus. 
The abscess cavity should be thoroughly cleansed with sterile salt solu- 
tion and drained by gauze or tube. 

Complications Following Operations on Brain. — Secondary 
Meningitis. — Secondary meningitis by extension of the septic condi- 
tion from the seat of operation sometimes occurs, indicating during 
convalescence a failure to keep the wound clean. Veins or lymphatics 
may cam- an infected clot to the meninges, or the infection may be 
carried by direct continuity of tissue. A meningitis following an opera- 
tion upon the skull or brain will be most pronoimced in the vicinity 
of the incision, but when once inflammation arises, there will be cloudy 
or purulent cerebrospinal fluid, with exudation. Constitutional sepsis 
is a rapid sequel of meningitis in most cases. It may extend not only 
to the base of the brain, but to the spinal meninges. The ordinary 
clinical symptoms of weak rapid pulse, elevated and variable tempera- 
ture, delirium, hyperesthesia of the surface, restlessness, retained urine, 
constipation, intense headache, glistening eyes, trembling and busy 
hands, followed by stupor, hebetude, contracted pupils, which often 
do not react to light, make up a picture which admits of little doubt. 
Should meningitis be more pronounced along the fissure of Rolando, 
local spasms or paralyses are to be expected. The results of treatment 
are not favorable. Attention to the secretions, rest, removal of all 
exciting causes, the application of an ice-bag to the head, cool sponging 
if the temperature is high, strychnin to support the pulse, will probably 
be all that is to be done. The free opening of the woimd and an attempt 
to obtain drainage are often followed by good results. It is frequently 
impossible to arrest the inflammation, but this much is certain, that 
when inflammation occurs in a closed cavity, it is always important 
to have the cavity opened, so that the products of inflammation may 
find an exit and tension be relieved. After trephining, in case a fissure- 
fracture has traveled to the base of the skull, basilar meningitis is very 
likely to follow, and, since many important cranial nerves are given off 
from this part of the brain, a disturbance of their functions will be noted. 
However, the inflammation is rarely limited to the base of the skull, 
but extends to the upper part of the spinal meninges and so retraction 
of the head and interference with, and disturbance of, the upper spinal 
muscles are likely. 

When there has been any evidence of extension of the inflammation to 



OPERATIONS. 



151 



the spinal meninges, spinal puncture or laminectomy may be resorted to, 
with irrigation; but the results, up to present, of either of these pro- 
cedures do not warrant great hopes of recovery. (Abstract from Warren- 
Gould.) 

Postoperative Hernia Cerebri. — Postoperative hernia cerebri is 
an evidence of sepsis, local perhaps. The protruding mass, which is 
brain-substance, at first is small; but subsequently may become large, 




Fig. 35. — Postoperative Cerebral Hernia. 
(Reported by Cushing, " S., G. & Obs.," Vol. i, No. 4.) 

may slough, may suppurate, but always projects above the level of the 
skull. It will pulsate and is soft to the touch — not vascular, however; 
it is possible to cut away portions of the hernia, for brain-substance is 
insensitive. When portions of the hernia are cut away, new portions are 
apt to protrude through the skull. As inflammation diminishes, the 
hernia will sink within the head and cicatrization take place, or the 
patient may die of general sepsis. 



152 



POSTOPERATIVE TREATMENT. 



Treatment. — An attempt to force the brain back into the skull will 
give rise to symptoms of compression not advantageous to the patient. 
Cutting off pieces of the brain down to the level of the skull is not called 
for. A clean dressing, with a light compressing bandage to hold the 
dressings in place, and so exercise a very slight pressure on the hernia, 
is all that is necessary. The surface of the hernia may slough, and 
if so, the dressing should be changed and cleanliness continued. As 
the wound becomes clean and cicatrization takes place, the hernia will 
disappear. (Warren- Gould.) 

Trephining. — Closure of the Wound. — The flap of dura is brought 
into place, and is secured to the unwounded part of the membrane 
by a few fine catgut sutures; space, however, must be left for drainage. 
The trephine disc or any large fragment of bone which has been pre- 
served may be replaced as nearly 
as possible in situ. In case the 
bone is not replaced, as it is in 
the osteoplastic flap of Wagner, 
and it is desired that the bony 
skull- wall shall be restored, Keen, 
in clean cases, preserves, in warm 
salt solution, the bits of bone re- 
moved by the rongeur forceps, 
and when the dura is closed he 
"sows" these fragments on the 
dura, like a thin layer of gravel, 
and then closes the scalp over this. 
This brings about restitution of the bony wall. The replacing of the 
trephine disc or of large fragments of bone is not necessary, and should 
be resorted to only when the portion removed is very large and when 
the scalp at the time of the operation is intact. Such replacing of por- 
tions of bone should not be practised in cases of compound fracture, 
as infection is more than probable. 

The flap or flaps of scalp are now brought into place by silkworm-gut 
sutures, and drainage is secured by introducing a bunch of horsehair 
threads here and there betwxen the stitches or by a slight gauze drain. 
The skin is well cleansed, the wound is dusted with iodoform, and a 
suitable dry dressing is applied and is secured by means of a tight flannel 
bandage. 
After-treatment of Cases of Trephining. — The patient is kept 




Fig. 36. — Hernia Cerebri. — {Bryant.) 



OPERATIONS. 153 

absolutely at rest, and the room occupied should be perfectly quiet. 
The head is kept a little raised. The wound is dressed upon ordinary 
surgical principles. In case of fracture, or in case of trephining for 
epilepsy, etc., in which no lesion of the dura exists, draining by catgut 
will suffice. In cases of trephining for the removal of a brain tumor, 
or the evacuation of a cerebral abscess, drainage with a tube is necessary. 
In the former case the tube is retained for twenty-four hours only; in 
the latter it is retained until the abscess cavity has practically closed, 
and is shortened as often as required. In a few instances of intracranial 
suppuration a second opening in the skull may be necessary to insure 
perfect drainage. 

If, after the removal of the drainage-tube in any case pain and throb- 
bing in the wound are complained of, and if the scalp flap appears to be 
raised up, it may be necessary to reopen the track of the drainage-tube 
to allow pent-up discharges to escape. Sutures may be removed at 
any time after the fifth or sixth day, or be retained as long as appears 
needful. If a hernia cerebri form, it can best be treated, so far as my 
own experience goes, by means of a pad of gauze and wool, kept constantly 
wet with absolute alcohol. The surface of the protrusion hardens 
and forms a species of scab or cuticle, which in time becomes quite tough, 
and affords an efficient covering to the exposed brain. (See Hernia 
Cerebri.) The patient will need to remain in bed until the wound is 
soundly healed. From two to three weeks will represent an average 
time. The diet is such as is advised after any grave operation. 

Secondary or Postoperative Hemorrhage. — Hemorrhage from the 
brain tissue is seldom troublesome. The arterioles for the most part 
run perpendicularly to the cerebral surface. Most of the bleeding is 
soon checked with sponge pressure, with ice, or by the use of sterilized 
adrenalin solution. The actual cautery should never be employed to 
arrest bleeding from the brain. Extensive divisions of surface blood- 
vessels may be avoided by lifting them out of the sulci between the 
convolutions, and replacing the pia after the operation. 

The treatment of bleeding from the venous sinuses is best controlled 
by pressure. 

Postoperative Adhesions in Brain Surgery.— Method of Pre- 
venting. — One of the most troublesome complications following 
operations on the brain, especially for the relief of epilepsy, is the post- 
operative formation of adhesions, involving the cortex of the brain and 
its covering membranes. The adhesions occur most frequently between 



154 



POSTOPERATIVE TREATMENT. 



together, preferably with chromicized catgut, and before the completion 
the dura and pia or between the pia and brain-substance, and forming 
thus mar the success of the most brilliant operations. Many devices 
have been used to prevent the formation of adhesions ; of these, gold-foil, 
rubber tissue, gold-beater's skin (Outten), and other like substances 
have been used with variable success. Thin metal plates of gold and of 
silver were popular for a time, but are now discarded. In a recent 
issue of the "Journal of the American Medical Association," M. L 
Harris, of Chicago, suggests the use of silver-foil. He writes as follows : 
"The best material to be used and the details of technic, however, 
are questions still to be worked out. There are some points which 
appear to be well established. For instance, the traumatism incident 




Fig. 37. — Resection or Skull. — (Binnie.) 

to the operation should be as slight as possible. A bone flap which can 
be replaced is preferable, when possible, to the trephine opening with the 
bone left out. Before the introduction of any substance hemorrhage 
should be perfectly controlled and all blood-clots removed. The sub- 
stance should extend well beyond the edge of the area involved in the 
adhesions. There should be no openings or breaks in the substance. 
The material must be one which can be sterilized. The wound must 
heal in a perfectly aseptic manner. The question of material is not 
so well settled. Whether the organic substances, such as egg-membrane, 
prepared ox peritoneum, etc., will prove of value remains to be deter- 
mined. They have not been used often enough to relieve one of the 



OPKRATIONS. 



155 



theoretic doubt of their eihcaey. Thin rubber tissue has been used 
a number of times with good results. The author has a patient who 
has carried a good-sized piece of rubber tissue in his skull for several 
months with an excellent result. One disadvantage of the rubber is'jts 
tendency to roll up after it has been inserted. It then not only fails 
to fulfil its purpose, but may be an actual cause of irritation. The 
author knows of one unreported case in which the rubber, which had to 
be removed some months after it w T as introduced, was found rolled up. 
The rubber may also be disintegrated by granulations. 

"Of the materials thus far proposed, the author believes the' thin 
foils are the best, and of these he prefers the silver-foil. It is thin and 




Fig. 38. — Use of Bone Gouging or Cutting Forceps After Trephining. — 

(Binnie.) 



soft and smooth. It conforms to all irregularities of the surface on which 
it is laid. As many layers may be applied as may be necessary to secure 
a smooth, unbroken surface. It is not only tolerated kindly by the 
tissues but exerts a beneficial influence on granulating or healing surfaces. 
The foil may be placed directly in contact with the brain-tissue, between 
the pia and dura, or wherever it may be necessary to accomplish the 
purpose desired." 

OPERATIONS UPON THE JAW. 

Excision of the Superior Maxilla. — After removal of the bone 
it is essential that all hemorrhage be checked, and the periosteal flap 
from the roof of the mouth and front of the bone be carefully sutured 



156 POSTOPERATIVE TREATMENT. 

of any form of resection, either of the upper or lower jaw, the buccal 
mucous membrane should be accurately adjusted if divided, and deeper 
sutures should be carefully placed. If the nasal cavity is opened, the 
soft tissues should also be carefully closed by sutures. In resections 
of the lower jaw when the attachments of the geniohyoglossus muscles 
are divided and the tongue tends to fall backward upon the glottis, 
the tongue and muscles should be drawn forward and the severed attach- 
ments sutured as far forward as possible to the buccal and deeper tissues, 
after which the wound should be packed with gauze and drained from 
the outside. This drainage may be removed so soon as it loosens — 
usually the third or fourth day. 

After-treatment. — The patient should be well sustained by careful 
liquid nourishment for the first forty-eight hours, if necessary, by 
means of a short esophageal tube. Morphin should be administered 
hypodermatically if required. The gauze plug should not be large 
enough to bulge the cheek and cause a strain upon the sutures. It 
should be removed in twenty-four hours, as it soon becomes offensive 
if retained. Every possible care should be taken that the mouth and 
the wound cavity are kept clean. The patient should be raised up in 
bed by means of a bed-rest, so as to facilitate the escape of discharges. 
He should rinse the mouth very frequently with some antiseptic solution. 
Carbolic acid (1 in 60 or 80) answers admirably. Two or three times 
a day also the cavity should be well washed out with a like solution from 
an irrigator provided with a wide-mouthed nozle. The surface wound 
should be kept dry, and dusted with iodoform. The feeding of the 
patient is a matter of the greatest importance. He may be fed for the 
first day or two with the esophageal tube. Through this tube milk, 
beaten-up eggs, beef-tea, and brandy can be administered as frequently 
as desired. 

If necessary, this mode of taking nourishment may be supplemented 
by nutrient enemas. So soon as the patient can swallow food without 
assistance the mouth must be washed out each time after food is taken. 
The skin- wound generally heals well, and if no complications arise the 
patient may be up in a week or ten days. When the wound is quite 
sound, the question of fitting an artificial palate or tooth-plate has to be 
considered. 

Excision of the Lower Jaw. — After-treatment. — The general 
features of the after-treatment have been alluded to in dealing with the 
upper jaw. The main difficulty is to keep the mouth sweet. A large 



OPERATIONS. 



157 



pouch is left in the floor of the mouth, and in this food and the secretions 
of the mouth must of necessity collect, and here they are apt to decom- 
pose. If care is not taken, this pouch becomes the seat of the foulest 
possible sloughs. It is difficult for the patient to wash the mouth out 
efficiently, as it is painful to move the remaining portion of the jaw, or 
even to move the head. The best wash is a 1 percent or 2 percent 
solution of carbolic acid. 

The cleansing of the mouth is best effected by irrigation. For the 
first few days— if possible, for the first ten days— it will be well if the 
food can be administered through a tube, so that none can find its way 




Fig. 39 



-Resection of the Lower Jaw. — (Dennis.) 



into the mouth. If this is done, and if the mouth is washed out every 
hour with a gentle stream from an irrigator, the parts can be kept in 
excellent condition, and healing will proceed rapidly. If a drainage-tube 
is employed, it should be removed in twenty- four hours, and the escape 
of the fluids in the mouth through the skin-wound should not be encour- 
aged after that time. 

The patient should occupy the sitting position as much as possible 
and every care should be taken that he is well fed. In the manner of 
feeding I have usually employed the nasal tube, which has been passed 



158 POSTOPERATIVE TREATMENT. 

after a little cocain had been introduced into the nose through an atom- 
izer. The foulness of the mouth in a neglected case is indescribable, 
and the persistent attempt to avert decomposition is a main element 
in the after-treatment. (Treves.) 

After partial resection of the lower jaw, a carefully padded and 
adjusted splint should be applied to prevent movements of the part and 
keep the lower jaw in proper relation to the upper. In section of the 
ramus for ankylosis passive motion should begin the third or fourth 
day after the operation, and be regularly maintained. It is usually 
necessary to use anesthesia for this purpose. Relapse is very likely to 
recur, however, unless the proper after-treatment is carefully carried out. 

EXCISION OF THE TONGUE. 

General Considerations. — Whether the operative method of White- 
head or of Kocher — those most commonly employed — be followed, 
after-treatment is very essential. 

Prior to the operation it is essential to have the teeth, mouth, and 
pharynx thoroughly cleansed by scraping away all tartar, by drawing all 
bad teeth, and by cauterizing all ulcerating patches. Small abscesses 
and collections of decomposing matter in the crypts of the tonsils should 
be disinfected after carefully slitting up their cavities. The avoidance 
of injury in any manner to the mechanism of swallowing is also very 
important; i.e., the muscles of the floor of the mouth, tongue, and 
pharynx, with their nerves of supply. Further, free escape must be 
given for the discharge and secretions from the mouth. It is only by 
careful attention to these points that the danger from decomposition of 
the exudation from the wound can be reduced to the minimum. It is 
likewise essential that the patient be placed, so soon as recovered from 
the anesthesia, in a half-sitting position, and so soon as possible he 
should assume the sitting posture or be gotten out of bed. The method 
which Kocher now employs, and which is described in a recent (1903) 
edition of his "Text-Book of Operative Surgery," is a modification and 
extension of the Sedillot-Syme operation, in which the lower lip is 
divided vertically and the symphysis menti is sawed through, permitting 
free access to the floor of the mouth. Kocher divides the soft tissue 
backward to the hyoid bone. All vessels are ligated as they are severed 
during operation. The wound is closed by wiring the divided bone and 
suturing the soft parts anteriorly, but an important point is that thorough 



OPERATIONS. 



159 



drainage is secured through the floor of the mouth, the gauze being 
carried through the skin-incision near the hyoid bone. The method of 
Kocher has the following advantages: the postoperative hemorrhage 
is very slight or more easily controlled, the secretions of the wound are 
drained away much more satisfactorily, and preservation of the tissues 
of deglutition along with their nerves, by which a better functional 




Fig. 40. — Anatomic Relations of the Parts Involved in Kocher's Present 
Operation for Removal of the Tongue by Median Division of the Lower 
Jaw. — {Kocher, "American Text-Book of Surgery") 

a, Line of division of the mucous membrane; b, lingual nerve; c, lingual vein; d, 
lingual artery; e, hyoglossus muscle; /, hypoglossal nerve; g, tongue; h, right geniohyo- 
glossus muscle; i, left geniohyoglossus muscle; k, geniohyoid muscle. 

result is obtained than by any other method. This preservation of the 
powders of deglutition is of the greatest importance in preventing secon- 
dary pneumonia, the great danger which threatens the patient. 

Method of After-treatment by Sir Frederick Treves. — "The patient 
may be allowed up on the third or fourth day, and in the majority of 
the cases I have treated at the London Hospital the patient has left 
the hospital between the seventh and the tenth day after the excision. 



l6o POSTOPERATIVE TREATMENT. 

"I have been very much disappointed with a solution of potash 
permanganate as a wash, and have long since given it up. Boric lotion 
is still more ineffective. 

"Some surgeons, notably Wolfler, have advised that the floor of the 
mouth be packed with iodoform gauze. I have tried this dressing, 
but cannot recommend it. Mr. Whitehead does not encourage his 
patients to consider themselves invalids. They get up on the day after 
the operation, and may on that day take open-air exercise. Food is 
administered by the mouth on the day after the excision. In the matter 
of rapidity of recovery, Mr. Whitehead's cases stand preeminent. 

" Many American surgeons prefer to pack the floor of the mouth with 
iodoform gauze in long strips which come out through the lower or 
counteropening, or through the most dependent portion of the external 
wound, which is partly closed, covered with iodoform gauze, and firmly 
bandaged. By far the best and simplest method, however, is to place a 
soft-rubber drainage-tube well into the floor of the mouth and have it 
pass out the external cut or wound at the lowest possible point. The 
tube should pass through the outer dressings of iodoform which are 
protected from saturation by rubber tissue. Over the outer opening 
of the drain tube is placed a layer of absorbent cotton, and over this a 
second or temporary bandage. The first or primary bandage, if applied 
tightly, adds much to the comfort of the patient and facilitates swallow- 
ing. The drainage-tube helps materially to keep the surface inside the 
mouth dry and clean. The mouth should be thoroughly irrigated with 
hot normal salt solution several times a day, and the external or tempo- 
rary dressings should be changed as frequently as necessity may require. 
The after-treatment in all these cases or methods of operating involves 
three great factors : First, the patient must be well fed; second, thorough 
drainage must be established from the mouth; third, the cavity of the 
mouth must be kept clean and sweet." 

Method of After-treatment by Kocher. — "Some surgeons simply 
dust the floor of the mouth with iodoform. Others resort to the objec- 
tionable practice of stuffing the mouth, or at least the lower segment 
of it, with gauze. I have dispensed with applications of any kind. The 
mouth is well washed out with an antiseptic lotion and is left. It must 
be remembered that the discharge of saliva is fairly copious, and renders 
any 'dressing' almost immediately ineffective. 

"The patient is encouraged to sit up in bed as soon as possible. 
Morphin should be avoided whenever it can be ; it dulls the reflex sensi- 



OPERATIONS. l6l 

bility of the patient, and may cause him to allow fluid to run down 
into the air-passages. 

"The patient must be impressed with the importance of allowing all 
discharge to escape from the mouth, and of swallowing none of it. The 
mouth must be kept constantly washed out. This rinsing of the mouth 
cannot be too frequently performed. Every half-hour in the day, and 
three or four times in the night, is not too often. The best wash is 
carbolic lotion (i in 60 to 1 in 80). 

''After certain of the washings, say, three or four times a day, the 
floor of the mouth is dried with a pledget of cotton- wool, and iodoform 
is dusted over the raw surface. It soon forms a more or less consistent 
pellicle over the stump. A watch must be kept for the symptoms of 
iodoform poisoning. During the first twenty-four hours the patient 
may be fed by the rectum, and ice only should be taken by the mouth. 
The use of ice should be very moderate, as it does little but fill the mouth 
with fluid, which gives the patient some trouble to get rid of. At the 
end of twenty-four hours the patient should swallow food. It is best 
given with an ordinary feeder, while the man sits upright, with his 
head inclined to one side. 

"The difficulty of swallowing is usually overcome with a little pa- 
tience and practice. Should the patient be quite unable to swallow, then 
he must be fed with an esophageal tube. One feature in the after- 
treatment of these cases must not be lost sight of. The patient must 
be well fed. As soon as enough nourishment is taken by the mouth 
the nutrient enemas may be discontinued. After every occasion upon 
which food is taken, the mouth must be well washed out. 

"Now and then the cavity may be flushed out with an irrigator. 
These cases demand the undivided attention of two nurses, one for day 
and one for night duty, for upon the careful nursing of the case as 
much of the success depends as upon the operation. 

"No drainage of the mouth cavity is needed in these cases. If the 
part becomes unduly offensive, a stronger solution of carbolic acid must 
be used, and the mere rinsing out of the mouth must be replaced by a 
flushing out of the cavity with the irrigator. 

"These perpetual washings-out of the mouth involve considerable 
annoyance to the patient, but they are necessary only for a few days, 
and it must be borne in mind that the usual cause of death after these 
operations is septic pneumonia." 



1 62 POSTOPERATIVE TREATMENT. 



CLEFT PALATE. 



After-treatment (Cheyne).— The patient is placed in bed with the 

head low and turned to one side so that the blood may trickle out through 
the mouth. There is often a good deal of shock, and the patient should 
be surrounded with hot bottles or be put upon a large hot- water pillow. 
Food should not be given until all danger of vomiting has ceased, and for 
the first four or five days nothing but liquids should be taken; during 
the first forty-eight hours these are best given iced. The food should 
consist of milk, milk and soda, or milk and lime- water. It is best given 
with a spoon, and later on from a feeder furnished with an india-rubber 
tube which is passed as far back as possible at the side of the mouth. 
After the fourth day bread and milk, custards, arrow- root, etc., may be 
given, but no solid food should be administered for at least ten days. 

The most important part of the treatment consists in keeping the 
patient absolutely quiet. Talking, laughing, crying, etc., must be 
guarded against as effectually as possible. The hands should be muffled 
if necessary and tied to the side to prevent the risk of the child sucking 
the thumb or fingers; or an effectual plan, and one that is less irksome 
to the child, is to mold small splints of cardboard or felt along the front 
of the arm from the middle of the upper arm to the middle of the fore- 
arm. This prevents the child flexing the elbow; he therefore cannot 
reach his mouth, but he can use his arms and can play with his toys, etc. 

At the end of that time the palate should be examined and the stitches 
removed, at any rate from the hard palate; in order to do this satisfac- 
torily it is well to administer an anesthetic. Should the union be good, 
all the stitches may be taken out then ; if at any part the union is doubtful, 
they should be left in for a few days longer. 

Complications. — There are two probable complications common 
to all operations for cleft palate: 

i. Bleeding. — As a rule, the hemorrhage, though free at first, is 
easily controlled by gentle sponge pressure. If it is obstinate, it gen- 
erally results from incomplete division of the posterior palatine artery 
or some of its branches. Secondary hemorrhage may also occur and 
is fairly common in weak, anemic children or in those who are the sub- 
ject of hemophilia. 

Treatment. — This is comparatively simple. If the hemorrhage is 
troublesome at the time of the operation and sponge pressure will not 
stop it, the clots should be carefully wiped from the region of the lateral 



OPERATIONS. 163 

incisions and the source of hemorrhage exposed. If it comes from a 
partially divided vessel at the end of the incision, the extension of the 
incision will probably suffice, especially if combined with firm pressure 
directly upon the bleeding point either with the finger or a small piece 
of sponge. The treatment of secondary hemorrhage is sometimes more 
difficult. In the first place, an attempt should be made to check the 
bleeding by syringing away the clots with iced boric lotion, and small 
pieces of ice inclosed in muslin may be pressed against the lateral incision 
from which the bleeding is coming. If this fails, an anesthetic should 
be given, and, after the blood-clot has been cleared away, the bleeding 
point should be exposed. If firm pressure on it is not effectual, and 
if the vessel cannot be picked up in forceps and tied, the bleeding will 
probably be coming from the posterior palatine canal, and an attempt 
should be made to stop it by temporarily plugging the canal with a 
fine probe. If this does not succeed, the canal may be plugged with 
Horsley's wax (see page 40). 

2. Failure of Union. — The other important complication is failure 
of union at some part of the cleft. The failure may be partial or entire. 
It generally happens that only one portion gives way, and it is most 
common to find a deficiency either at the extreme anterior end or about 
the junction of the hard with the soft palate. Nonunion may be due 
to one of three principal causes: 

(a) Imperfect Operation. — The cleft may be insufficiently pared, 
generally because each side has not been pared in a single piece and thus 
some part has been overlooked or only a very narrow portion removed; 
the tension upon the flaps may be so great as to interfere with union ; the 
flaps may be brought badly into apposition, one edge being curled up so 
that the raw surfaces are not together; the stitches may be tied either 
too loosely or too tightly; or the flap may be so bruised by rough handling 
that its vitality is seriously diminished. 

(b) Intercurrent inflammatory affections, such as a severe cold, the 
onset of a specific fever, or ordinary septic infection, may entirely 
prevent union. Septic infection of the line of incision is largely predis- 
posed by rough handling of the flaps. 

(c) Want of proper care in the after-treatment may bring about failure 
of union. Among the most important factors leading to failure of union 
after an otherwise perfectly satisfactory operation are excessive crying, 
vomiting, or mechanical violence produced by hard food, fingers, or 
foreign bodies thrust against the flaps. 



164 POSTOPERATIVE TREATMENT. 

It is well to remember that, unless union fails throughout the whole 
palate, the gap left after limited failure of union is diminished very 
considerably in the course of time by the granulations springing up 
around the hole. This is especially the case in the soft palate. 

Treatment. — The treatment in cases in which union seems doubtful 
is, of course, largely prophylactic, and every precaution must be taken 
in the way of careful operation and after-treatment to see that nothing 
interferes with union. Any intercurrent affection, such as a cold, should 
receive careful attention. If, when the wound is examined, there be 
any doubt as to the amount of union present, the stitches should not be 
removed for a fortnight or three weeks. Should failure of union occur 
at any part, it is well to wait until the edges are freely granulating, and 
then, after administering an anesthetic, to introduce fresh sutures and 
draw the flaps together without tension. It is not generally necessary 
actually to pare the edges when introducing stitches for the second time, 
although it may be advisable to scrape the granulating edges slightly. 
These second stitches should be left in for at least a fortnight. If this 
secondary union fails, it is well to delay further operative interference 
for a period of at least six months, so as to allow complete cicatrization 
and contraction to take place. The subsequent operation consists 
in paring the edges of the defect, making lateral incisions for the relief 
of tension, and then bringing the edges together. Unfortunately, if the 
union fails in the soft palate, the contraction leads to shortening of the 
palate, so that secondary operations seldom avail to bring about a per- 
fect result. Hence every possible care should be taken to secure union 
in the first operation. 

After-treatment (Treves). — The patient should remain in bed for 
a week. No food of any kind should be administered until all vomit- 
ing has ceased. The diet should be simple, and may consist for the first 
day of milk or milk and water only, and after that of beef-tea, broth, 
eggs, arrowroot, custard, and sago puddings, bread and milk, stewed 
fruit, and the like. Porridge, pounded meat, or fish may be given when 
a few days have elapsed. Two mistakes are frequently made in the 
after-treatment ; one is to starve the patient, and the other is to feed him 
so frequently with small quantities of food that the pharyngeal muscles 
are never at rest. One author, indeed, says that food should be admin- 
istered ''unceasingly." 

The patient should be fed as an ordinary patient is fed, but the food 
must be fluid, or at least perfectly soft, and must be swallowed slowly 



OPERATIONS. 



165 



and carefully. The pharyngeal muscles contract more completely 
around a small bolus than a large. This simple and almost fluid diet 
should be observed for two or three weeks, until, indeed, it is clear that 
the wound has healed or has broken down hopelessly. It is well to 
forbid much talking. For the first few days the less the patient speaks, 
the better. 

One important factor must not be overlooked — the mouth must be 
kept clean. It is often rendered foul by decomposing milk and beef-tea, 
which remain in the recesses of the mouth, owing to the patient's exag- 
gerated belief in the evils which attend swallowing. The best wash 



(^€ Hy 



(f l) 





Fig. 41. Fig. 42. 

Types of Cleft Palate. — (Brewer.) 



is a warm solution of carbolic acid (1 in 100 to 1 in 80). Boric-acid 
lotion also answers well. 

The mouth should be rinsed out after every meal, and at other times 
as occasion suggests. I am in the habit of having the wound washed 
at least twice a day with a warm boric-acid solution, which is applied 
to the palate by means of a "scent spray." It is agreeable to the patient, 
and it keeps the part free from incrustation. 

The advice that the palate in young children should not be inspected 
for one week after the operation is hardly consistent with the practice 
which obtains in the treatment of wounds elsewhere. 



i66 



POSTOPERATIVE TREATMENT. 



The sutures need not be removed until fourteen days or three weeks 
have elapsed. Sutures of silkworm-gut and fine silver set up singularly 
little disturbance, and may be retained for weeks, but it is obvious that 
if firm union has not taken place in three weeks, it will probably not 
take place in five. 

Results. — The success of the operation may be compromised by 
severe vomiting, by the swallowing of solid food, by the development of 
whooping-cough or an eruptive fever, or by the feebleness of the patient's 
health. It must be remembered that the closure of the cleft does not 
remedy the defective articulation. The soft palate in these cases of 




Fig. 43. 
The edges of the cleft are 
being pared with a probe- 
pointed bistoury after pass- 
ing the sutures. It is better 
to pare the edges before 
passing the sutures. — {Ber- 
nard and Huette.) 




Fig. 44. 
Method of Rink: The su- 
tures d d and c c in place, the 
third, b, being inserted from 
behind forward by a curved 
needle-holder, a; the lips are 
held tense with the forceps. 
— (Bernard and Huette.) 




Fig. 45- 
The sutures being fas- 
tened, the lateral incisions 
a b are made to relieve ten- 
sion by division of the 
tensor palati muscles. — 
(Bernard and Huette.) 



congenital deformity is not only deficient in the median line, but deficient, 
as a rule, throughout. It is unduly short, and after the most successful 
operation it is doubtful if the palate is ever so completely restored that 
it is capable of shutting off the mouth from the nasal passage. 

The operation, however, places the patient in a position to attain 
normal articulation. It enables him to be educated to speak naturally. 
This education is tedious, and involves a great expenditure of time and 
trouble, but it is remarkable what excellent results may follow, even in 
cases which cannot be considered from a surgical point of view to be 
eminently successful. 



OPKRATIONS. 

HARK LIP. 



167 



Operations Upon Infants. — So soon as the bleeding has stopped, 
the line of incision is painted with collodion and the following method, 
introduced by Lord Lister, is of value as a support to the wound: A 
double thickness of gauze is cut in the shape of a bat's wing, one broad 
surface lying over each cheek and the narrow intervening portion passing 





Fig. 47- 

(Binnie, after Esmarch and Kowalzig.) 





Fig. 48. Fig. 49. 

Nelaton. — {Binnie, after Esmarch and Kowalzig.) 





Fig. 50. Fig. 51. 

(Binnie, after Esmarch and Kowalzig.) 



Fig. 52. 



across the lip. One end of this dressing is then fastened to the cheek 
with collodion, and, when it is dry, the two cheeks are pushed forward 
and held in this position while the other end is fixed with collodion to 
the other cheek and held in position until it is quite dry; in this way all 
tension is avoided. If the nostril is unduly small after the stitches are 
put in, it is well to put a small drainage-tube in it to leave breathing 



1 68 POSTOPERATIVE TREATMENT. 

space; fatal cases are recorded from the valve-like action of the upper 
lip combined with the blocking of the nostrils by clot obstructing the 
breathing. In time the nostrils will become quite patent. (Treves.) 
After-treatment. — The stitches can usually be removed at the end 
of a week; in fact, the horsehair and catgut sutures may be removed 
in two or three days, the deeper silkworm-gut stitches being left for a 
week or more. After the operation the child should be entirely fed by 
the spoon with very great care to prevent injury to the line of incision; 
the point of the spoon should be introduced at the side opposite to that 
operated on. After the wound has healed, the patient may be put on 
the bottle. 

OPERATIONS ON THE NOSE. 

Subcutaneous Paraffin Injection. — (Abstract from "Progressive 
Medicine," March, 1904.) 

The secret of postoperative success or failure of the operation depends 
largely upon the kind of paraffin used and the aseptic technic of the 
procedure. Perusal of the various writings upon this subject shows 
clearly that paraffins having different melting-points have been employed ; 
thus, Gersuny himself used white vaselin or the unguentum paraffin, a 
mixture of solid and liquid paraffin, a substance having a melting-point 
of 97 to 104 F. Objection has been raised to the employment of this 
form of paraffin on the ground that it remained liquid for some hours 
after its injection into the tissues, and therefore favored embolism, also 
that infiltration into the neighboring tissues is possible after its intro- 
duction. It has also been asserted that a slow absorption of this material 
is possible, and that consequently permanent improvement was not to 
be expected from the operation. 

Still another drawback presents itself in the fact that the melting- 
point of the vaselin used by Gersuny was relatively about the normal 
temperature of the human body, that the individual might readily, under 
the influence of some marked feverish condition, acquire a temperature 
equal to or higher than the melting-point of the vaselin, the consequence 
of which is sufficiently obvious. 

Eckstein, of Berlin, employs a solid paraffin having a high melting- 
point of 120 to 130 F. This substance, therefore, has a melting-point 
considerably higher than that of the tissues into which it is injected. 
It solidifies rapidly and thus remains in the same situation uninfluenced 
by muscular contraction or other forces. 



OPERATIONS. 169 

Broeckaert has more recently modified Eckstein's procedure. He 
prefers to use a paraffin melting at 56 C. Mosckowicz now also injects 
the unguentum paraffin in a solid state. After melting and drawing 
it into the syringe, he there allows it to cool down until solidification 
takes place, and then in the form of a fine thread he injects it into the 
tissues. It is preserved in sealed bottles after the manner of antitoxin 
serums. The paraffin must be thoroughly sterilized, the sterilizer 
in which the syringe is boiled also serving as a water-bath in which to 
melt the paraffin. The postoperative effect depends also largely upon 
the amount of the material used. It is therefore necessary to avoid the 
introduction of any excess, as undue tension and destruction of the skin 
may follow. To avoid this it is sometimes better to repeat the operation 
if the need arises. From one-half to one dram or one and a half drams 
is the amount ordinarily required. During the injection the material 
is molded according to the necessities of the case. A needle-puncture 
should be sealed by a collodion dressing. 

Postoperative Effects. — As a result of the injection, the skin 
usually becomes white and frequently presents a somewhat swollen 
and tense appearance. During one or two succeeding days there may 
be redness and sometimes edema, which is usually of a transient nature. 
The application of iced boric- acid dressing will minimize the tendency 
to painful reaction. No second injection should be permitted until all 
evidence of any local irritation resulting from a previous operation has 
subsided. The results of this method of correcting external deformities 
of the nose are very favorable. 

Should suppuration occur, an incision should be promptly made and 
the paraffin allowed to escape through the sinus or opening which has 
formed. The after-treatment is similar to the treatment of other septic 
wounds. 



CHAPTER IX. 
OPERATIONS (Continued) 



CHAPTER IX. 

OPERATIONS. (Continued). 

OPERATIONS UPON THE NECK (TRACHEOTOMY, LARYN- 

GOTOMY, ETC.). 

Technic. — If the operation has been performed for the removal of a 
foreign body, the entire wound can be closed for primary union. If, how- 
ever, a tracheal tube has been inserted, it is imperative that the patient 
should be placed in a warm bed, preferably in a semi- erect position, and 
made as comfortable as possible. The air must be kept fresh and at a 
temperature of about 65 F., and all possible draft avoided. 

The cannula should be made of aluminium. Other metal tubes are 
heavy, and when allowed to remain in the trachea for a few days, often 
excite ulceration by pressure. Every metal cannula should be double 
and fixed in position by means of silk or tape passing through the shield 
and tied around the neck. When it is intended that the tube shall be 
worn for some time, it is better not to rely upon a single or straight ver- 
tical incision of the trachea, but to exsect a circular portion of the anterior 
wall equal in size or a little larger than the required cannula. The result 
will be found more comfortable to the patient, and enable the cannula 
to be reinserted more easily. 

The after-treatment of these patients must be conducted with scrupu- 
lous care. The wound must be kept perfectly clean. Great care should 
be observed to keep the orifice of the cannula free from mucus and the 
inner tube clean. A tracheal aspirator for the removal of mucous mem- 
brane, or possibly foreign bodies, from the air-passages of the trachea 
should always be at hand. This does away with the filthy and dangerous 
practice of sucking the tube or cannula when partially obstructed. A 
piece of dry gauze should always be placed over the tube to prevent 
the entrance of foregin bodies. This is neatly accomplished by taking 
an ordinary pill-box, and with bottom and top removed, stretch a piece 
of gauze over the remaining pasteboard rim and cap this over the orifice 
of the tube, holding it in position by the bandages carried around the 
neck. The tube or cannula should frequently be cleansed of secretion. 

i/3 



174 



POSTOPERATIVE TREATMENT. 



This should be done as rapidly as possible, the tube being thoroughly 
disinfected and oiled before it is again introduced. 

After the difficulty of breathing has been relieved by the operation, 
children usually fall asleep for several hours and should not be awakened. 
A nurse should remain constantly beside the patient for a number of 
hours after operation. The inner tube should, as a rule, be removed 
and cleaned every two hours. Any mucus or membrane that is coughed 
up should be wiped away at once with a piece of gauze dipped in carbolic 
solution. If the tracheal aspirator is not attainable and the tube becomes 
blocked with mucus, a small feather may be used for cleansing purposes. 
If the breathing becomes difficult and the cannula is clear, a steam 




Fig. 53. — Operation for Tracheotomy. — (Bryant.) 



atomizer or croup kettle with a solution of sodium bicarbonate, 20 grains 
to an ounce, will prove very beneficial to the patient. Unless the cause 
of obstruction is a permanent one, after twenty-four to forty-eight hours, 
attempts should be made to remove the cannula by temporarily stopping 
the tube with the finger or a piece of gauze. The patient should be al- 
lowed to attempt to breathe through the mouth, but before permanently 
removing the tube, the patient should be gradually accustomed to breath- 
ing through the mouth by plugging of the cannula, and if on removing 
the tube asphyxia or spasms occur, the tube must be immediately rein- 
serted. If the tube has to be retained for more than five or six days, an 
india-rubber tube should be substituted for the metal. A plan adopted 
by Dyer when there is great difficulty in getting the patient to breathe 



OPERATIONS. 175 

through the mouth is to intube the larynx first and then remove the tra- 
cheal tube. After twenty-four to forty-eight hours the laryngeal tube 
may be removed, and the trachea closed by an antiseptic gauze pad and 
sterilized adhesive strips. 

With regard to the steam tent, or "croup bed," and the measures to 
be adopted to keep the tube clean, I cannot do better than quote the 
excellent and practical observations of Mr. Jacobson upon this head: 

"While fully aware of the need of moisture when the atmosphere is 
dry, when the membrane tends to crust and become fixed, I am of the 
opinion that the unvarying rule of cot-tenting and use of steam is dis- 
advantageous. The weakly condition of children with membranous 
laryngitis, and all they have gone through, must be remembered. Be- 
lieving that such seclusion, and so little admission of air, tend to increase 
the asthenia and any tendency to sepsis, I much prefer to be content to 
keep off drafts by a screen, which allows of the escape of vitiated air 
above, using steam, if needful, according to the size of the room, fireplace, 
etc., and according to the kind of expectoration, whether easily brought 
up by the cough or feathers, or viscid, quickly drying and causing whis- 
tling breathing. If the temperature can be otherwise kept up to 6o° or 
65 , I much prefer to use a thin flat sponge often wrung out in a warm 
solution of boric acid. The inner tube must be frequently removed and 
cleansed — even- hour or two at first. If the secretions dry on and cling 
to it, they are best removed by the soda solution mentioned below. At 
varying intervals between the removal of the tube, any membrane, etc., 
which is blocking it, appearing for a moment at its mouth and then 
sucked back, must be got rid of by inserting narrow pheasant feathers, 
and twisting them round before removing them. If the exudation is 
slight, moist, and easily brought up by cough or feather, sponging or 
brushing out the trachea is not called for, but should be made use of 
when there is much flapping, clicking, or whistling of the breathing; 
and if this is harsh, dry, or noisy, instead of moist and noiseless, two of 
the best solutions are sodium bicarbonate, 5 to 20 grains to an ounce of 
water, or a saturated one of borax with soda. These may be applied by a 
hand or steam spray over the cannula for five or ten minutes at a time, 
at intervals varying according to the relief which is given, or applied with 
a laryngeal brush, feather, or bit of sponge twisted securely into a loop of 
wire. When any of these are used, the risk of excoriation and bleeding 
and the fact that only the trachea and large bronchi can be cleansed, 
must be borne in mind ; and with regard to manipulations for cleansing 



176 POSTOPERATIVE TREATMENT. 

the trachea and removing the inner tube, it is most important to remem- 
ber that the caretaking may be overdone, and a weakly child still further 
exhausted by meddlesome interference. " 

Dietetics. — In the matter of nourishment, soup, pounded meat, milk, 
broth, etc., should be given at first, if necessary through a nasal or esopha- 
geal tube. This, however, is not often required. Difficulty in swallow- 
ing is liable to occur on the third or fourth day. A little care and en- 
couragement will soon enable the patient, if a child, to overcome this 
difficulty. Nutrient enemas are rarely necessary except at first, in case 
there is nausea or vomiting. 

INTUBATION. 

As a postoperative measure, intubation may be employed to relieve 
dyspnea or as a curative agent to effect dilatation in deformity of the 
interior of the larynx. In the adult it is applicable to a large variety of 
conditions of laryngeal stenosis, both acute and chronic, among which 
may be mentioned (of the former) obstruction to the larynx or edema 
of the glottis from any cause; operations upon the larynx; incised wounds 
or internal violence, as from attempted endolaryngeal operation, foreign 
body, or the like. The chronic conditions in which it is indicated are 
such cases of postoperative stricture as may be amenable to treatment 
by the division of cicatricial band and systematic dilatation. It is also 
useful in some cases of laryngeal neoplasm and in laryngeal paralysis 
threatening asphyxia, which sometimes follow operations upon the throat. 

In fractures and other injuries of the laryngeal cartilages involving 
displacement the presence of the tube acts as an excellent support for 
keeping the displaced parts in proper position, and from its unyielding 
nature makes possible the application of supplementary means for sup- 
porting the parts from the outside. 

The insertion of the tube is less difficult in the adult than in the child. 
It should be done, if possible, with the aid of the laryngoscopic mirror, 
although this is not absolutely necessary, the sense of touch in one expert 
in the operation being sufficient. The difficulty of reaching the larynx 
with a forefinger of ordinary length, and the greater precision with which 
the tube can be managed when seen in the laryngoscope, make the latter 
a very useful aid. In passing the tube the larynx should first be anes- 
thetized with cocain. The patient should be seated as for the ordinary 
laryngoscopic examination, and the tube, aided by the mirror, should 



OPK RATIONS. 



177 



be introduced as in the infant, except that the finger of the operator 
is not used as a guide. Instead of this, as is customary in the passage 
of any endolaryngeal instrument, the aid of the patient is depended upon 
to open the larynx either by the act of phonation or of deep inspiration. 
The use of a mouth-gag in the adult is not required. Intubation in 
suitable chronic cases has practically superseded all older methods of 
dilation. 




Fig. 54. — O'Dwyer's Intubation Set. 



The larynx tolerates the presence of the tube with great readiness, 
one of O'Dwyer's patients, without his knowledge, having voluntarily 
carried a tube without removal for fourteen months. Too long reten- 
tion may injure the larynx, and is not recommended. Such a case 
should of course be watched, and the tube removed and reinserted as 
often as required for cleanliness, the condition of the parts, or the neces- 
sity for more active dilatation through the insertion of a tube of larger 



178 



POSTOPERATIVE TREATMENT. 



diameter. The instruments used for the adult are very similar to those 
for children, except that, owing to the excessive weight of metal, the 
larger sizes may be made entirely of hard rubber or of the latter and metal 
combined. 

The proper time for removing the tube from the larynx will depend 
on the age of the patient, the character of the disease, whether of slow 
or rapid development, and the progress of the case. In diphtheria the 
younger the patient, as a rule, the longer the tube will be required. In 
children under two years of age it is better to leave it in seven days. 
When the above disease has developed slowly, and has therefore run a 




Fig. 55. — O'Dwyer's Intubation Instruments. 
A. Gold-plated tubes. B. Scale. C. Denhart's mouth-gag. D. Obturator or intro- 
ducer. E. O'Dwyer's extractor. 



greater part of its course before calling for operative interference, the 
tube can be dispensed with earlier — sometimes so soon as the second or 
third day. If the patient cannot be seen within a reasonable time, it is 
safer, if progressing favorably, to leave the tube in position for seven or 
eight days, and the exceptions are few in which it will be necessary to 
reinsert it after this time. The tube should always be removed on the 
recurrence of severe dyspnea, because it is sometimes impossible to 
ascertain with certainty whether or not it be partially obstructed. The 
best evidence to the contrary is a good respiratory murmur or numerous 



OPKR \ 1'IONS. 



179 



rales over the lower posterior portion of the Lungs. Even under these 
circumstances the lumen of the tube may have been encroached upon. 
In patients refusing nourishment after intubation it is useless to remove 
the tube for the purpose of feeding, unless it has been in long enough to 
give some reasonable hope that its further use will not be necessary, 
as it is difficult to convince children for some time that they can swallow- 
any better than before. If no dyspnea recurs in half an hour after 
the extraction of the tube, it is safe to leave the patient, if not at too 
great a distance to be reached within two or three hours. 

In feeding children after intubation great care must be taken that 
food be kept out of the trachea, otherwise a fatal result is pretty certain. 
Liquid or semisolid food may be 
given through an esophageal tube or 
by enema. The best method is to 
allow the child to swallow it w T hile his 
head is depressed and a little to one 
side. (Dennis.) 

ESOPHAGOTOMY. 

After-treatment. — The after-treat- 
ment of these cases involves con- 
siderable care, and often not a few 
difficulties. 

The patient should he in bed, with 
the head and shoulders well raised. 
The neck must be fixed and made 
rigid, and this can be effected by 
means of one of the simpler forms of 
apparatus employed in cases of cervi- 
cal caries or torticollis. It is essential 
that the part be kept at rest, and un- 
less the head be fixed it will be found 
that the region of the wound is very 
frequently disturbed, especially when 
the patient is fed. 

The longer the patient can be kept, 
without food by the mouth, the better. 
by nutrient enemas. Thirst may be 
warm w T ater. The patient may be fed 




Fig. 56. — Davis Apparatus for 
Torticollis used after Oper- 
ation FOR ESOPHAGOTOMY. 

A. Abdominal belt. B. Front con- 
necting strap. C. Head brace. 
D. Steel loop. E. Chin strap. 
G. Shoulder brace or pads. 

immediately after the operation, 
The strength must be maintained 
relieved by rectal injections of 
by a tube on the second or third 



l8o POSTOPERATIVE TREATMENT. 

day. The tube should be soft, and should be passed by the mouth. 
This method of feeding must be repeated until the parts are sound. If 
the wound in the gullet has been closed and has remained closed, the 
tube may be given up after seven or ten days. If the wound is left open, 
or if it reopens after it has been closed, the tube should be employed until 
the wound in the neck is granulating well and has been reduced to small 
dimensions, and until it is evident that the cut in the gullet has healed. 

When the aperture in the esophagus remains free, there is a great 
disposition for the cervical wound to become very foul, in spite of ordi- 
nary attention. The mouth should be frequently rinsed out with a 
carbolic solution, and the wound, which should be dressed very lightly 
with gauze, should be irrigated with some aseptic solution many times 
a day. When the patient is fed with the tube, a little food is very apt 
to escape into the mouth, and also out of the wound. Both mouth and 
wound should, therefore, be well washed out after each feeding. It is 
when milk is extensively employed that the parts tend to become most 
foul. 

Iodoform forms a very suitable material for dusting upon the wound. 
The chief cause of death in these cases is septicemia, consequent upon 
the foul condition of the wound. Other elements in the mortality are 
cellulitis, pneumonia, and exhaustion. 

OPERATIONS UPON THE THYROID GLAND, GOITER, ETC. 

Technic. — Before closing the incision all hemorrhage must be com- 
pletely arrested. The smaller arteries should be ligated, as accidental 
or recurrent hemorrhage after these operations is very frequent, vomit- 
ing being the most exciting cause, owing to the vascularity of the parts. 
To control or prevent persistent oozing after operation for goiter some 
surgeons now saturate the entire wound with a weak solution of adrena- 
lin chlorid just before the final sutures are placed. 

Liability to recurrent hemorrhage is so very common that the patient 
should be watched carefully for several hours following the operation. 
Hemorrhage beneath the deep fascia may so compress the trachea as 
to cause death by asphyxia. A sudden onset or attack of difficult breath- 
ing, accompanied with cyanosis, calls for hurried relief. The wound 
should be quickly torn open and issue given to the blood. Instead of 
sealing these wounds with collodion, as is sometimes done, if a small 
piece of gauze or guttapercha is introduced before closing the wound, 



OPERATIONS. 



IttI 



hemorrhage will be quickly noted and other complications avoided. 
Usually within twenty-four to thirty-six hours after the operation when 
no drainage is used, marked swelling of the tissue around the gland is 
often observed; this, however, rarely calls for treatment and gradually 
disappears. During convalescence, symptoms of thyroidism may sud- 
denly appear, the most prominent of which are tachycardia, tremor, 
headache and drowsiness, and rapid breathing with marked exhaustion. 
This is believed to be due to the absorption of colloid material. When 
this does occur, the wound 
should be opened and care- 
fully irrigated. Rest and 
protection from excitement 
are essential conditions to 
successful treatment. Ice 
should be applied to the 
head, neck and heart, tem- 
perature reduced by spong- 
ing, salt solution by sub- 
cutaneous infusion and per 
rectum, morphia in small 
doses. (Bloodgood.) Med- 
ically, the treatment is 
mainly directed to the 
symptoms, the remedies 
mostly used being bromids 
as nerve sedatives, and 
digitalis to slow and steady 
the pulse. Later, nux 
vomica in large doses, as 
recommended by Newton, 
may prove efficient. Sub- 
normal temperature with 

rapid breathing, associated with cyanosis and swelling of the vessels 
of the neck, may call for adrenalin and other heart stimulants with 
hypodermatocylsis. Of 68 cases reported by Oppenheimer, there were 
9 deaths within twenty-four hours. 

The other complications are as follows: Tetany of various degrees 
due to removal or injury of the parathyroid. In these cases which are 
very unusual one should give the patient parathyroids. This can be 




Fig. 57. — Colloid Goiter. — {Richardson, after 
v. Bruns.) 



182 



POSTOPERATIVE TREATMENT. 



obtained from a butcher from thyroid gland of animals. Dr. Halsted 
had one such observation with good result. 

Myxedema. — This is, as a rule, a late complication of gradual devel- 
opment. It is observed in some cases of accessory thyroid tumors which 
have been removed and the patient has no other thyroid tissue. In 
these cases the thyroid extract should be given. 

After any operation upon the thyroid, especially exophthalmic goiter, 
there may be an acute thyroidism, which must be separated clinically 
from tetany and myxedema. The clinical picture resembles exoph- 
thalmic goiter symptoms of high degree. In such cases the wound 
should be opened to see if there is retention of serum. 

ABSCESS OF MASTOID. 



Treatment. — After removal of pus and all necrosed bone, the wound 
should be treated after the open method. Free drainage is requisite. 
The cavity of the abscess and the antrum should be very gently packed 
with 5 percent iodoform gauze. This packing is removed, when loosened 
on the third or fourth day. The antrum and cavity should be freely 

irrigated with an antiseptic 
lotion posteriorly, and the 
fluid allowed to pass out of 
the canal. When thoroughly 
cleansed, the cavity and an- 
trum should again be 
packed lightly with gauze. 
It will be necessary in some 
cases to leave a drainage- 
tube in situ, especially when 
the abscess-cavity is very 
foul and the pus is fetid. 
When a drainage-tube has 
been inserted and there is a 
discharge of pus, the parts should be irrigated with a weak boric-acid 
solution, and afterward covered with iodoform gauze and absorbent 
cotton and bandaged. Surgeons in some instances, when there is a 
chance of healing of the aseptic wound, reinsert the disk of bone. If 
there is much discharge the dressings should be changed each day. 
"The bone which separates the mastoid cells from the lateral sinus 




Fig. 58. — Opening the Mastoid Antrum. — 
(Esmarch and Kowalzig.) 



OPERATIONS. 183 

is very* thin, so that when erosion of the bone occurs, inflammation may 
easily extend to the lateral sinus, causing thrombosis of the same, and 
emboli may be thus transmitted to the cerebrum or cerebellum and form 
an abscess, or abscess may be developed by direct inflammation through 
the dura mater, or in rare instances by inflammation extending to the 
cerebellum through the sheath of the auditory meatus. Abscesses are 
also found between the dura mater and pia mater." (Dennis). 

Complications. — The sudden onset of a rigor, followed by a rise 
of temperature, headache, vomiting, etc., indicates meningitis. Under 
such circumstances the wound should be at once reopened. All drain- 
age should be removed and mild antiseptic lotions used freely. Should 
these means not suffice, meningitis or abscess may be expected, and every 
effort should be made to locate and evacuate the pus. It is to be remem- 
bered, however, that the brain-substance, being poorly supplied with 
lymphatics, abscess in its interior does not, as a rule, cause rise of 
temperature. More frequently in abscess of the brain-substance the 
patient's temperature is normal or subnormal. 

We should examine carefully with a probe to see if a sinus exists in 
the upper wall. If not, we may then suspect a temporosphenoid abscess, 
and an incision should be made upward above the zygomatic process, 
and with a trephine remove a disk of bone 3 cm. in diameter at a point 
(see Fig. 58) of the external auditory canal from 2.5 to 3 cm. above the 
external meatus. In abscesses in the brain due to middle-ear disease 
Keen trephines at "Barker's point" — ij inches above and ij inches 
back of the extreme auditory meatus. Horsley also follows this rule. 
After removing the disk of bone, if the abscess is large, there will prob- 
ably be some bulging of the dura mater into the opening. There may 
or may not be absence of cerebral pulsation. The dura should be divi- 
ded and the arachnoid and pia mater examined. By means of a hypo- 
dermatic syringe and needle the different portions of the brain can be 
explored for abscess. The needle should be introduced so as to cover 
the cranial surface of the tegmen tympani. After the pus has been 
evacuated the abscess- cavity should be washed out with a very weak 
boric-acid solution and but very little pressure used; otherwise the 
brain-substance may be injured. 

EMPYEMA OR PLEUROTOMY. 

Postoperative Treatment. — When a permanent treatment is to be 
provided, the opening should be made at the lowest part of the cavity 



184 POSTOPERATIVE TREATMENT. 

in the mammary line, by removing the cartilage of the sixth rib ; in the 
lateral region, the right pleura may be opened by removing the ninth 
rib ; and the left, by removing the tenth rib ; posteriorly in the scapular 
line on either side, by removing the twelfth rib, the presence of fluid 
being previously ascertained by puncture or aspiration. After a free 
opening has been made, a probe or the finger is introduced to ascertain 
the deeper part of the cavity, over which a second opening may be made 
by resection of a portion of the rib. In this way provision is made for 
syringing the pleural cavity through the two openings. (Kocher.) 

Schede has demonstrated that expansion of the lung takes place best 
when the thorax is opened at the deepest and most posterior part. By 
following Schede's procedure, the cavity may be at once washed out, 
a short T-shaped drainage-tube being used to permit the free escape of 
fluid. Repeated washing out of the cavity should be avoided, as, accord- 
ing to Schede, it interferes greatly with the adhesions of the pleura. Fetid 
empyemas, however, should be washed out, and retention of pus must 
be prevented by efficient drainage. In purulent pleural exudation 
thorough and early evacuation is the best procedure. Complete mobil- 
ity and expansion of the lung is best obtained by early and thorough 
operation. The dressings becoming soiled permit the air to escape from 
the cavity upon forced expiration, but by compressing the drainage- 
tube or opening, the ingress of air may be impeded. 

Hutton seeks by means of a very ingeniously contrived mechanical 
device to permit thorough drainage, and upon forced expiration, the 
escape of air; but by the action of the valve in the device the air is pre- 
vented from entering the cavity, and thus secures the operation of atmos- 
pheric pressure, preventing collapse of the chest walls. 

Delorme has lately suggested a method for bringing about the closure 
of old empyema cavities, which, when available, gives a better result 
than ordinary methods. After opening the pleura he separates exten- 
sively the adhesions to the lung and then performs a decortication of the 
cicatrized tissue from the surface of the lung, thus enabling the lung to 
expand sufficiently to come in contact with the inner wall of the chest. 
If on dividing the pleural adhesions it is found that the lung is still 
capable of expansion, and that the adhesions can be peeled off, nothing 
further is required, providing the lung expands sufficiently to fill up the 
cavity; but if the lung does not expand sufficiently, Depage's operation 
should be resorted to, and one or more ribs resected from the pleural 
surfaces of the raised flap, commencing with the lowest one. 



OPERATIONS. 



185 



Christie, Jr., reports a most gratifying result from the following 
method : The ease is treated as a simple drainage case — that is, with re- 
section of one rib and drainage through a tube for three weeks. At this 
time union and moderately firm cicatrization of the cutaneous and sub- 
cutaneous incision will have been secured, and there will remain a simple 
sinus leading into the pleural cavity. By means of a simple apparatus 
which is attached to the vacuum chamber of an ordinary aspirator he 
forcibly extracts all the air from the pleural cavity and at once secures 
the effect of full atmospheric pressure within the lung and against the 
thoracic wall, which forcibly induces the immediate expansion of the 
lung, after which the wound is effectually plugged by means of a water- 




Fig. 59. — External Wound Partly Sutured; Double Drain in Place. — (Senn.) 



cushion and rubber dam eight inches wide; the purpose of the dam being 
to form an impervious contact with the chest walls. 

Should irrigation of the pleural cavity at any time be considered 
desirable, normal salt solution or weak iodin solution only should be 
used. The drainage-tube must be continued until all discharges have 
ceased entirely. The patients, who are, as a rule, very much emaciated, 
should be placed upon tonics with forced nutrition. 

Senn's Method of Drainage and After-treatment. — Tubular drain- 
age is the ideal method of draining a suppurating pleural cavity. Two 
fenestrated tubular drains the size of the little finger and about four 
inches in length, securely fastened together with a large safety-pin or a 
stitch through each end, should be used for this purpose. This precau- 



i86 



POSTOPERATIVE TREATMENT. 



tion is absolutely necessary, as drains have been frequently lost in the 
pleural cavity for want of securing with a large safety-pin. After insert- 
ing the tubular drain, the external wound is sutured in the usual manner. 
The curved incision, as previously described, not only exposes the rib 
more freely than the straight incision as usually practised, but also is 
much better adapted for efficient prolonged drainage. 

It is not advisable to irrigate the cavity the day the operation is per- 
formed, and irriga- 
tion at this time is 
always contraindi- 
cated if the em- 
pyemic cavity is in 
communication 
with the bronchial 
tubes. Irrigation 
may become neces- 
sary later if the 
suppuration con- 
tinues. If irriga- 
tion becomes neces- 
sary at any time, 
care must be exer- 
cised in the selec- 
tion of the solution ; 
carbolic acid and 
corrosive sublimate 
in the usual strength 
are dangerous and 
should never be 
used. A nontoxic 
and yet potent anti- 
septic solution 
should be used — 
either a saturated solution of aluminium acetate or Thiersch's solution. 
Either of these solutions is efficient as an antiseptic, and nontoxic even 
when used in large quantities. The value of the double drain is made 
more apparent when it becomes necessary to irrigate the pleural cavity. 
By placing the patient on the opposite side the fluid that enters the chest 
through one of the tubes escapes through the other as soon as the cavity is 




Fig. 



60. — Dressing after Operation for Empyema. — 

(Semi.) 



(MTK VI'lONS. 



I8 7 



full, thus washing it out thoroughly. By placing the patient on the af- 
fected side the cavity is emptied, when the same procedure is repeated until 
the solution returns clear. The solution used must always be heated 
to blood-temperature, as irrigation with a cold solution is fraught with 
danger. I have seen, in the case of a child, almost fatal collapse attend 
irrigation of the pleural cavity with a solution at room-temperature. 
It required persistent and prolonged efforts to restore the suspended 
respiration by the administration of stimulants and artificial respiration. 
The external dressing consists of a large and thick cushion of sterile 
gauze and cotton to absorb the fluid as fast as it escapes, and at the same 




Fig. 61. — Bryant's Method of Drainage in Empyema. 

Collapsible rubber bag with thumbscrew, attached to rubber drainage-tube. Dressings 

applied and apparatus fastened in place. 



time to provide the wound with a filter to prevent postoperative infection. 
There is no special advantage in using medicated in place of sterile ab- 
sorbent material, so long as the compress is removed, as it should be, as 
soon as indications of saturation appear on its surface. The best way 
to retain the dressing in place and to prevent the entrance into the pleura 
of unfiltered air is to substitute for the ordinary bandage the rubber- 
webbing bandage, or to place over the gauze roller, over the upper and 
lower margin of the dressing, a band of the rubber- webbing bandage. 



1 88 POSTOPERATIVE TREATMENT. 

Change of dressing and antiseptic irrigation become necessary as often 
as the dressing becomes saturated. For the purpose of obviating fre- 
quent changes the dressing should be at least six inches thick and cover 
the whole side of the chest. As the cavity diminishes in size the drains 
are shortened from time to time, and sooner or later one of them can be 
dispensed with. Premature removal of the drain is often followed by 
relapse; drainage must not be suspended until the surgeon can satisfy 
himself by careful examination that the pleural cavity has become oblit- 
erated. Should the lung fail to expand sufficiently in the course of a few 
months to place the cavity in a condition for definitive healing, Schede's 
thoracoplasty is the operation of choice, as Estlander's multiple rib 
resection has not yielded the expected results in the practice of many 
operators, including myself. 

It is well for the surgeon to keep close watch on the size of the empy- 
emic cavity during the after-treatment, not only for the purpose of keep- 
ing himself well informed of the progress of the healing process, but also 
with a view to determining the time when it is safe to abandon drainage. 
For a long time it has been my custom to place my patient, at stated 
intervals, on the opposite side, then to fill the cavity with one of the anti- 
septic solutions used for irrigation, then evacuate the chest by reversing 
the position, and measure the quantity of fluid removed. This procedure 
can be relied upon in giving the size of the cavity, and should be em- 
ployed systematically at fixed intervals, to ascertain the proper time for 
the removal of the drain. 

AMPUTATION OR EXCISION OF THE BREAST. 

Technic. — The operation, although extensive, is usually performed 
with little loss of blood, and therefore with little shock. The wound 
should be closed by bringing together the flaps so that the axilla at least 
is completely closed. A single drainage-tube should be inserted well 
below the lowest part of the incision and extend upward between the 
chest wall and muscular tissues as far as the clavicle. Any part of the 
wound which cannot be closed should be at once grafted by Thiersch's 
method. 

"The functional disturbances which follow such an extensive opera- 
tion and removal of muscle are not so severe as one would expect, be- 
cause the anterior fibers of the deltoid are able to pull the arm forward, 
and the latissimus dorsi to adduct it. The complete removal of glands 



OPERATIONS. 



is a more important matter, and the obstruetion to the flow of lymph, 
especially if the main vein has been ligated, is a more serious complica- 
tion. In this case a solid edema develops, with elephantiasis of the 
arm, which may last for months or years, and which interferes much 
more with the function of the arm than does removal of the muscle." 
(Kocher.) 

After-treatment. — A matter of considerable importance, so often 
overlooked in the after-treatment for excision of the breast, is the position 
of the arm during convalescence. Many surgeons teach or insist upon 
immobility, fixing the arm either by adhesive plasters or bandages imme- 
diately after the operation. This is not good practice. 

Triangular Dressing of 
Arm after Excision of 
Breast. — J. A. Bodine has 
devised a method of dress- 
ing the arm during healing 
after breast amputations. 
(Fig. 65, page 192.) He 
uses a triangular splint 
which places the arm at a 
right angle to the body. He 
calls attention to the conse- 
quent freedom with which 
the patients can use their- 
arms. He has been using 
this dressing in all such 
cases for the past few years. 
An isosceles triangle, made 
of light splint wood, held in 
position by rubber adhesive 
strips, is so placed against 
the side of the chest that 
the upper arm is at a right 

angle to the body, while the forearm in supination rests along one 
side -of the triangle with the hand resting upon the hip. The triangle 
presses along the body between the line of incision for removal of 
the breast and the posterior puncture made for the drainage-tube. 
The arm being in position, the patient is perfectly comfortable while 
in bed and also while walking about. Adherence of the skin flap and 




Fig. 62. — Illustrates the Customary Method 
of Bandaging or Dressing the Arm after 
Excision of the Breast. 



190 



POSTOPERATIVE TREATMENT. 



scar to the under surface of the arm after enucleation of the axillary con- 
tents is an inch and a half to two inches nearer the shoulder than it is 
when bound against the chest. It is this difference in position of attach- 
ment of the scar and skin flap to the arm that gives such freedom from 
cicatricial contraction following amputation of the breast. 

Murphy fixes the arm at a right angle to the body by means of a 
plaster-of-Paris cast (Fig. 63). Dawbarn has several times employed 
the method demonstrated by Bodine. It is more comfortable because 
the abduction of the arm slides the scar so that it does not adhere to the 




Fig. 63. — Murphy's Method of Dressing aeter Excision of Breast, Plaster- 
of-Paris Cast Applied, Fixing the Arm at a Right Angle to the Body. 



region of the vein nor the main lymphatics. Patients at times have 
been made very miserable after amputation of the breast by swelling of the 
arm, due to adhesion of the scar, the forearm and arm becoming large 
and edematous and annoying the patient for a long time. This may 
be avoided by carrying the incision up the middle of or even posterior 
part of the axilla, although the main dissection is sharply forward in 
the anterior portion of the axilla where the main vessels He. In com- 
menting upon this method of dressing Dawbarn ("Albany Medical 
Journal") writes: "There is only one muscle which can take the place 



OPERATIONS. 191 

of the pectoralis major and minor, both of which must be entirely removed 
in the modern operation, and that is the deltoid. It is wonderful how 
tills muscle, hypertrophied, and being inserted into the outer third of 
the collar-bone, with a very poor leverage, accomplishes its mission." 
In the case of women who have very weak deltoids, it has been part of 
his regular operation of late years to dissect free from the clavicle one 




Fig. 64. — Shows the Ordinary Result with 
Contracted Scar and Limited Motion of 

Arm. 



inch of the anterior edge of the deltoid, and to carry it inward so far as it 
will easily go, and then to sew it to the stump of the pectoralis major. 
That muscle, in course of time, becomes hypertrophied, and it helps 
a great deal ; but in cases in which this operation is performed it obviously 
would not do to use the isosceles triangle, with its necessary abduction 
of the arm. In the technic just described, as to the deltoid, the cephalic 
vein is liable to cause trouble, and he generally ties it off, but this may not 
be necessary if great care is taken. It is only when the axillary vein is 
involved in the cancerous growth that saving the little cephalic vein be- 
comes a matter of importance. 

For several years we have abandoned the customary or fixed 



192 



POSTOPERATIVE TREATMENT. 



method of dressing as wholly unnecessary, if not harmful. The arm 
should be practically free, and the patient allowed to move it gently 
as early as possible. The results are often surprising: pain ceases much 
sooner, and a free and movable arm is the outcome. Fig. 66 illustrates 




Fig. 65. — Bodine's Method of Dressing after Breast Amputations, Also 
Showing Angular Splint. 



the author's method of bandaging with the arm free. A wedge-shaped 
pad of absorbent cotton holds the arm outward and prevents contact 
with the breast. Fig. 67 illustrates freedom of motion a few weeks 
following the operation. 

The after-treatment is practically the same as after other operations 



OPERATIONS. 



193 




Fig. 66. — Author's Method of Dressing after Amputation of Right Breast. 
Arm Free and Movable. 




Fig. 67. — Same, Showing Mobility of Arm Twenty-one Days after Amputation 

of Breast. 

13 



194 POSTOPERATIVE TREATMENT. 

or large wounds. All saturated dressings should be removed as early as 
possible, and fresh ones applied over the wound after twenty-four hours. 
The drainage-tube should be shortened at the daily dressings until all 
discharge ceases. The stitches require removal in from nine to fourteen 
days, support being given with sterile adhesive straps. 



CHAPTER X. 

OPERATIONS ON THE STOMACH, LIVER, 
AND INTESTINES. 



CHAPTER X. 
OPERATIONS ON THE STOMACH, LIVER AND INTESTINES. 

OPERATIONS UPON THE STOMACH. 

General Remarks. — In gastroenterostomy and other operations 
upon the stomach faulty technic or failure to select a proper site for the 
anastomosis not only retards recovery, but often complicates seriously the 
postoperative treatment of these cases. Patients requiring such surgical 
interference are very frequently markedly emaciated, and the stomach, 
as a result of the decomposed food and retained contents, very frequently 
becomes elongated or distended to such a degree as to cause a deformity 
in its outlines. This element of deformity is an important factor in the 
explanation of the unsatisfactory conditions which persist after many 
of these operations, and must not be overlooked. (Ochsner.) 

In order to secure proper drainage of the stomach it is essential that 
the lowest possible place in the stomach should be chosen. The selec- 
tion also of a proper point in the small intestines, not too close to the 
pylorus, and, lastly, the avoidance of tension of both gut and stomach, 
are likewise of the greatest importance. (Mayo.) Good and sufficient 
drainage is manifest by immediate improvement in the patient's nutri- 
tion and general condition. When there is evidence of retention of 
blood or mucus within the stomach immediately following the operation, 
the pharynx should be cocainized to prevent retching and vomiting, a 
stomach-tube inserted, and gastric lavage with normal salt solution 
gently given, in order not to overdistend the stomach. It is often sur- 
prising to find how much fluid will collect in the stomach after this 
operation. (Ochsner.) It is my experience that the use of the Murphy 
button in gastroenterostomy is attended by more discomfort or pain to 
the patient than the ordinary suture method, the mechanical weight of 
the button causing an unpleasant feeling or dragging sensation; and it 
sometimes happens in greatly reduced patients that a sudden jar or 
jolt, such as a paroxysm of coughing, sneezing, or vomiting, may cause 
a loosening of the button or drag it from its position in the stomach. 
When the Murphy button is employed in gastroenterostomy, it is there- 

197 



198 POSTOPERATIVE TREATMENT. 

fore advisable to reinforce the place of anastomosis by employing the 
adjacent omentum as a covering, as recommended by Nicholas Senn 
and others. 

Postoperative Treatment. — The patient should not He flat on the 
back in bed after stomach operations, especially after gastroenter- 
ostomy, since the escape of stomach contents into the intestine is facili- 
tated by the patient being slightly propped up. In some cases, too, 
turning on the right side also facilitates the outflow of stomach contents. 
It is unnecessary to state that the patient must not move himself, but 
must allow the nurses to change his position. This change of position 
also has an influence on the bowels, since it often relieves gaseous or 
fecal accumulation. 

Lavage. — If vomiting and eructation continue after the second day, 
and especially if at the same time the temperature is elevated, the mouth 
dry, and the tongue sticky and coated, it is almost certain that there 
is some decomposition of stomach contents. It these contents are allowed 
to remain in the stomach, they will probably produce a fatal issue, 
either by setting up diarrhea, by keeping up vomiting, or by absorption 
of toxins. It is very important that they should be removed at once; 
to do this, a stomach- tube must be passed, and the stomach thoroughly 
washed out with some antiseptic, such as salicylic acid, followed by plain 
boiled water, which must be continued until the fluid returned is quite 
clear. Feeding must be recommenced immediately after the lavage, 
as this will be a favorable time for the absorption of nourishment. 
The lavage must be repeated on the next day if vomiting or eructation 
continues. In some cases it may require to be done daily for five or 
six days. 

Some hesitation might be felt at passing a stomach-tube forty-eight 
hours after suture of the stomach, and injecting water to wash out its 
contents, since this might place a strain on the stitches; however, it is 
far better that a suture should undergo a slight strain than that it should 
be soaked in a putrid liquid ; besides, the wound in the stomach is firmly 
sealed at the end of forty-eight hours, and it will probably resist any 
pressure that is likely to be exerted in gastric lavage. The lavage, of 
course, must be done gently, the patient lying on his back, and the fluid 
introduced by means of a funnel which must not be more than three 
feet above the patient's head; it is removed by siphon action, not by 
expression. 

Laxatives. — A goodly number of cases of operations on the stomach 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 19Q 

never require any aperient, and the bowels act naturally on the second 
or third day; in some instances the other extreme is reached, or a trouble- 
some diarrhea may follow which may cause a fatal issue without leaving 
any signs at necropsy. In all cases of diarrhea the amount of liquids 
given should be diminished, and tincture of opium must be administered 
by the mouth, and the stomach washed out; this will usually stop the 
diarrhea. 

Rectal Feeding. — Rectal feeding in all operations upon the stomach 
is requisite for several days, and some account of the best form of carry- 
ing this out will be useful. 

In the first place, before commencing nutrient enemas, it is best to 
wash out the bowel thoroughly with normal saline solution; this must 
be repeated each day to remove the debris. The patient should be 
lying on his back, and should not change his position for some time 
after the injection. The best method of introduction is to use a soft- 
rubber rectal tube the size of a No. 12 or No. 14 catheter, which should 
be passed about six inches up the rectum; connected with the tube is a 
funnel which should be raised two feet above the bed. This is better 
than a syringe, since the fluid will flow more evenly and slowly into the 
rectum, and so is more likely to be retained; the risk of forcing in air, 
too, is diminished. The whole enema should not exceed six ounces 
in bulk, and in some irritable rectums only three or four ounces should 
be given; it should be of a temperature of ioo° F., and should be given 
every four or six hours. Practically only substances in solution can be 
absorbed from the rectum, so unpeptonized milk or beef-tea is useless; 
stimulants, such as spirits, wine, tea, or coffee, are most readily absorbed, 
but extractives and peptones are also of value. The necessity of giving 
digested meat has been recognized for a long time, but the process of 
preparing the enemas has been much improved by the introduction of 
the various peptonizing or digestive powders now on the market. The 
older enemas were prepared with fresh pancreas. The following are 
a few of the best: 

1. Von Leube's: Five ounces of finely scraped meat is chopped 
very fine, and to this is added one and a half ounces of finely chopped 
pancreas; the whole is suspended in three ounces of lukewarm water, 
and stirred to the consistence of a thick pulp. This makes one injection. 

2. Mayet's: 150 to 200 grams of pancreas is bruised in a mortar with* 
tepid water at a temperature of ioo° F., and is then strained through a 
cloth; 400 to 500 grams of lean meat is chopped fine, and the strained 



200 POSTOPERATIVE TREATMENT. 

pancreatic fluid is mixed with the mince, together with the yolk of one 
egg. This is allowed to stand for two hours, and administered at the 
body-temperature; the quantity is sufficient for twenty-four hours' 
nourishment, and should be administered in two parts. 

3. Rennie's: Half a pound of lean meat is pulled into shreds and 
added to a pint of beef-tea; to this are added one dram of fresh pepsin 
and half a dram of dilute hydrochloric acid; the mixture is kept at a 
temperature of 99 F. for four hours, during which it is stirred constantly. 
If too great heat is employed, the digestion will stop. 

4. The enema which the author employs is made as follows : Milk 2 
ounces, strong beef-tea 2 ounces, yolk of egg 1, pancreatic solution 1 
dram. This is to be prepared one hour before use, and to be kept at a 
temperature of ioo° F. One-half to one ounce of brandy is added, 
when necessary, immediately before use. 

5. Terrier and Hartman recommended the following: Peptones 20 
grams, infusion of tea 100 grams, benzonaphthol J centigram, tincture 
opium 5 minims. Four of these are given during the twenty-four hours. 

6. Greig Smith's: One egg is beaten up in six ounces of milk, and 
two or three teaspoonfuls of meat jelly or peptones added. This is 
administered warm with or without half an ounce of brandy every 
five or six hours. 

7. Hunter Robb's: Peptonized milk 1 ounce, whisky J ounce, the 
whites of 2 eggs, common table-salt 14 grains. 

Nutrient suppositories are also used when the rectum is intolerant 
of injections, or they may advantageously be used alternately with them 
in cases requiring several days' rectal feeding. If used alone, they 
must be supplemented by an injection of about half a pint of hot saline 
solution once or twice a day. The suppositories are usually made of 
peptonized beef, a chocolate-colored paste which is prepared by digesting 
beef with acidified fresh gastric juice, and then concentrating the solution. 
The suppository contains 30 grains of this, and is stiffened with cacao- 
butter. These suppositories are made by most wholesale chemists, 
and keep only for a short time after the box is opened. It is best to 
use them freshly prepared. 

Lastly, Sansom has recommended the use of blood as an enema. 
Ox blood is usually employed, and must be defibrinated first; this can 
be obtained from a butcher by asking for whipped blood. It must be 
fresh, and will not keep more than one day. By the addition of one and 
a half grains of chloral to one ounce of blood all offensive odor is over- 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 201 

come. It is usual to inject two or three ounces of blood every two or 
three hours. 

In case rectal feeding has to be continued for any length of time it is 
well to change the composition of the enema, since the rectum does 
not appear to retain any one kind of enema long. If, too, the rectum 
be irritable, two or three minims of tinctura opii should be added to 
each enema. Some surgeons also add some disinfectant to each enema, 
either betanaphthol or salol; from 2 to 5 grains of each can be given. 
Alcohol also acts as a disinfectant, as well as a stimulant, so this is an 
additional reason for adding either brandy or red wine, as suggested 
by Ewald. (See also article on Rectal Alimentation.) 

CHOLECYSTOTOMY. 

General Considerations. — Operations upon the gallbladder should 
be deferred, if possible, until all symptoms of acute inflammation have 
entirely subsided. When catarrh or inflammation coexists, simple 
cholecystotomy should not be performed. A relatively small incision 
in the abdomen is usually all that is required. If the walls of the gall- 
bladder are found to be normal so that the indication is merely to remove 
the contents, especially gallstones, the gallbladder is drawn into the 
wound and fixed there firmly by means of forceps. Sterile gauze tampons 
are now carefully inserted well around the gallbladder to prevent infection 
and entrance of bile into the peritoneum. The fundus may now be incised, 
the fluid contents evacuated, and the calculi removed by means of a 
scoop and forceps. After the extraction of the stones the wound in the 
gallbladder is closed by a double row of sutures, as in suture of in- 
testines. The gallbladder is then replaced, all gauze packing removed, 
and the wound is carefully closed by deep sutures and sealed. Many 
surgeons, however, prefer to treat the wound after the open method, 
i.e., a strip of iodoform gauze is introduced down into the sutured gall- 
bladder and allowed to remain three or four days, after which it is 
removed, and if there is no indication of infection or leakage from the 
gallbladder, the wound is closed or drawn together with adhesive plaster. 
When gallstones have become impacted in the ductus choledochus, 
the surgeon is confronted with a new set of indications for treatment. 
The prognosis is then more unfavorable, because the patient is the 
subject of jaundice, and an old-standing icterus produces an exceedingly 
dangerous hemorrhagic diathesis. A larger incision is usually required. 



202 POSTOPERATIVE TREATMENT. 

The gallbladder is exposed. Iodoform gauze is gently but thoroughly 
packed around the gallbladder, and especially the lower portion, to 
prevent, as before, any possible infection of the peritoneum. The gall- 
bladder is drawn well into the wound and stitched carefully with four 
to six sutures to the subcutaneous tissues, but not to the skin. Block 
and other surgeons operate in two stages; this is required, however, 
only in exceptional cases when infection is present to such a degree as 
to endanger extension to the peritoneum. In these cases the safest 
plan is to wait; suitable gauze dressing and bandage are now applied 
over the external wound and the patient is removed from the operating 
table. Three or four days suffices to form complete adhesion between 
the tissues and to wall oft all danger of infection of the peritoneum. 
The gauze packing will soon become loosened, which permits its easy 
removal, and the patient is ready for the second stage of operation. As 
a matter of safety, the wound, or lower portion at least, should be again 
packed loosely with iodoform gauze. The gallbladder may now be 
incised and stones removed, after which a glass tube with iodoform 
gauze packed around it is inserted for the purpose of drainage and thus 
a cholecystostomy is done. Many surgeons make extensive use of this 
operation because they lay great weight on drainage of the bile-passages. 
By using Morrison's method for drainage where leakage is inevitable, 
a rubber tube is inserted through the wound in front and extends to the 
deepest part of the gallbladder, or the gallbladder may be drawn over 
the tube as far as deemed necessary, and fastened by means of a strip 
of iodoform gauze wrapped aroimd the tube including the gallbladder 
tissue, thus preventing all leakage. The rest of the wound is carefully 
packed with iodoform gauze. 

Many very serious cases thus treated have resulted ultimately in 
perfect recovery. In chronic inflammation with calculi but no pus, 
Ross passes a tube into the bladder, stitches the opening firmly around 
the outer wall of the tube, packing the wound with iodoform gauze to 
wall off the peritoneum. Another packing is put in at the bottom of 
Morrison's pouch; the latter is removed about the fourth or fifth day and 
the former in one week or ten days, when the impacted stone can be safely 
removed. 

In all cases of protracted icterus special stress must be laid upon the 
most careful arrest of hemorrhage, owing to possibility of a fatal reac- 
tionary hemorrhage occurring from a small vessel. Capillar}' oozing in 
these cases usually appears the second or third day following operation. 



OPERATION- OK STOMACH, LIVER, AND INTESTINES. 



203 



Mayo Robson recommends as a preventive measure the use of calcium 
chlorid, 20 grains or more even- four hours for several days prior to the 
operation. When there is protracted icterus, instead of incising the 
gallbladder, Kocher recommends choledocholithotripsy with the finger 
or forceps. This can be performed safely, however, only when the 




Fig. 6S. — Illustrates Morrison's Method of Drainage of the Gallduct, 
Showing First Layer of Dressings in a Fleshy Subject. 



stone is soft and can easily be grasped; otherwise the open method 
must be employed, relying on firm gauze packing and pressure to over- 
come the hemorrhage. Cholecystenterostomy, so far as after-treatment 
is concerned, is a much better procedure than cholecystotomy, especially 
if the operation is performed by the aid of a Murphy button of small 



204 POSTOPERATIVE TREATMENT. 

caliber. The latter has been shown to be well adapted to this operation 
because of the rapidity and the ease with which it can be adapted and 
the certainty of rapid union which it offers; and, lastly, it allows of the 
immediate closure of the external wound and saves the patient the 
unpleasantness of an external fistula. 

Since the postoperative treatment of operations upon the gallbladder 
is dependent so largely upon drainage, I deem it advisable to give 
in detail other popular methods. 

Kehr's Method of Drainage after Operations on the Gallbladder. 
— Kehr's wide experience in gallstone surgery has led him to the con- 
viction that it is wise to incise and sound the common bileduct in every 
case of gallstone, and that every choledochotomy should be followed by 
drainage of the hepatic duct. This procedure combined with cholecys- 
tectomy has given the best results and the safest protection against recur- 
rence, and is indicated in every case in which it does not add materially 
to the operative dangers. 

Drainage of the hepatic duct is secured by inserting a rubber drainage- 
tube through the choledochotomy incision and pushing it in toward 
the liver for the distance of four centimeters. The tube is fixed to the 
choledochotomy wound, and the remainder of the wound is closed by 
silk sutures. The ends of all the sutures are left long to permit of their 
withdrawal at a later period. The drainage-tube is then surrounded 
with gauze strips folded lengthwise. The first tampon is laid over the 
foramen of Winslow; the second, firmly over the surface of the liver 
from which the gallbladder was excised; the third above the cholecys- 
tectomy incision on the ligamentum hepatoduodenal ; and the fourth 
on the ligatures of the cystic arteries and ducts and the sutures of the 
common bileduct; while the fifth tampon is placed between the drain- 
age-tube and the stomach or duodenum. 

Berger thus presents his conclusions after a study of 97 cases of 
gallstone in which drainage was employed by the above method in Kehr's 
private hospital. 

1. Drainage of the hepatic duct is to be preferred to incision and 
subsequent suture of the duct, because (a) is exerts a curative action 
on the coexisting cholangitis; (b) it permits of the later extraction of 
stones not removed at the time of the operation; and (c) it can be per- 
formed more quickly. 

2. Drainage of the hepatic duct is generally indicated in cases of 
active cholangitis, and in the cases in which it is not possible to remove 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 205 

all the stones from the hepatic and common ducts at the time of the 
operation. 

3. Drainage of the hepatic duct is also advisable after every case 
of choledochotomy, even though the bile is clear and the presence of 
further stones cannot be demonstrated. 

4. It is the safest and best procedure to be employed in the cases 
in which the history and clinical signs point to stone in the biliary pas- 
sages but in which no stone is found at the time of the operation. It 
is also to be recommended in every case of cholelithiasis, provided the 
operative dangers are not too greatly increased thereby. 

5. It is contraindicated in cases of acute suppurative cholecystitis 
on account of the dangers of spreading infection. Exception may be 
made to this rule when the patient behaves badly under the anesthetic 
and tends to become cyanotic when the tissues in the depth of the wound 
are handled. 

6. Drainage of the hepatic duct may be comparatively easy or ex- 
tremely difficult, depending upon the conditions found at the time of 
the operation. The best location for the incision is in the supraduo- 
denal portion of the duct. Firmly fixed concretions must be removed 
by special incisions (hepaticotomy, papillotomy). Fistulas should not 
be allowed to close until the bile is clear and the surgeon feels convinced 
that all inflammation has subsided and that no more stones are lodged 
in the hepatic or common ducts. 

7. The results of drainage of the hepatic duct are extremely satis- 
factory. It not only prevents further extension of an existing cholan- 
gitis, but it also brings about a cure. It permits of the subsequent 
extraction of stone in about 17 percent of all cases, and thereby prevents 
recurrence, which could not have been avoided after suture of the 
choledochotomy incision. 

8. The benefits to be derived from drainage of the hepatic duct 
are not unlimited. It is valueless in cases of diffuse cholangitis and in 
cases in which numerous gallstones occupy a position high up in the 
liver. 

9. Drainage of the hepatic duct is not in itself an especially danger- 
ous operation. In uncomplicated cases its mortality (from pneumonia, 
vomiting of blood, and acute dilation of the stomach) is not more than 
2 or 3 percent. 

10. Complications, such as extensive cholangitis, long-continued 
icterus and cholemia, extensive adhesions, hepatic cirrhosis, pancreatic 



206 POSTOPERATIVE TREATMENT. 

affections, fistula formation between the biliary system and the ali- 
mentary tract, increase the mortality. 

ii. In cases of cholangitis, carcinoma of the pancreas or biliary 
passages, and suppurative hepatitis, the mortality is nearly ioo percent. 
The high mortality in these cases cannot be ascribed to the operative 
procedure, but is due to the too long- continued medical treatment 
or to the nature of the affection. 

12. Early operation affords the best chances of lowering the per- 
centage of fatalities. 

Cook's Method for Drainage of the Gallbladder.— A simpler 
method for drainage of the gallbladder after cholecystostomy is the one 
devised and practised by George J. Cook. It is performed as follows: 

The drainage-tube employed should be of large caliber and possess 
firm walls so as to be not easily compressed. Its proximal end is firmly 
fixed in the gallbladder by a purse-string suture. Its distal end should 
not project more than one and one-half to two inches beyond the edges 
of the wound. To this end is firmly tied an extra large and extra thick 
condom or rubber sac. The gauze dressings are next applied; upon 
these is placed the condom or rubber sac, and this is well surrounded 
and covered with cotton. All are retained in position by a binder 
bandage snugly adjusted. It can readily be seen that by this method 
we have produced an artificial gallbladder and it lies in close proximity 
to the gallbladder which is to be drained. This so-called artificial 
gallbladder is removed once or twice every twenty-four hours, emptied, 
and thoroughly cleansed, after which it is again placed in position. 

After the fourth to the sixth day the tube and iodoform gauze may 
be removed, and if there is no obstruction of the gallducts, the fistulous 
tract may now be permitted to heal by granulation. One of the greatest 
drawbacks to the open method of treatment is the time required for 
the wound to heal, six to eight weeks being usually necessary. 

After-treatment. — Following operations on the gallbladder or bile- 
ducts considerable pain and nausea and vomiting for several hours 
are common. Hence nothing but small quantities of hot water should 
be given by the mouth for twenty- four hours; a hypodermatic injec- 
tion of morphin and strychnin may be advisable immediately after 
the operation, with rectal feeding for a few days. Attention to the 
bowels and fluid diet are practically the same as have been referred to 
under laparotomy. 

When the common duct has been incised or the gallbladder opened, 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 207 

the dressings should be changed frequently and dry sterilized gauze 
applied at each dressing. The sutures are removed in due course and 
the drainage-tube is dispensed with as soon as the fistulous tract appears 
to be sufficiently sound. This will probably be at the end of a week 
or ten days. The sinus should be frequently washed out and the 
parts kept scrupulously clean. The fistula usually closes without 
complication in from three to four weeks. In many instances, how- 
ever, it remains patent for months or years. Mayo reports that a few 
patients upon whom a cholecystotomy has been performed suffer from 
slight colic and sometimes transient jaundice during the first month 
or two after discharge from the hospital. These symptoms he considers 
due to the inability of an adherent gallbladder properly to empty itself. 
In most cases no secondary operation or special treatment is required. 

For persistent biliary fistula the fistulous tract should be firmly 
packed daily with 5 percent iodoform gauze dipped in balsam of Peru, 
over which a firm compress is applied, or if granulations appear slug- 
gish, silver nitrate may be used. Though often very slow in healing, 
a permanent fistula is rare, except when the gallbladder has been wrongly 
attached directly to the skin, in which case a slight resection of the 
parts usually becomes necessary before healing will result. 

Mayo Robson's Method of Treatment after Choledochotomy and 
Operations on Bileducts. — "Expedition in operating is an important 
factor in lessening shock, especially in abdominal surgery, for it stands 
to reason that prolonged manipulation and exposure of the viscera, 
in patients so ill as the class of cases we are now considering must 
generally be, will be badly borne, for it is not only the work of the surgeon 
but the deep anesthesia, that adds to the shock, since for these opera- 
tions to be expeditiously performed the muscles must be well relaxed. 
Choledochotomy should occupy from half an hour to an hour, and only 
in case of unusual complications, a little longer. 

" After operation a pint of saline fluid with one ounce of brandy is 
given by enema, this being repeated if called for. 

" Subcutaneous injections of saline fluid or intravenous infusion are 
very rarely required. 

"Beyond teaspoonfuls of hot water or hot tea from time to time, all 
feeding is by the rectum for the first twenty-four hours, though, if there 
is no vomiting, the teaspoonful of water is increased to a tablespoonful, 
or even two, every hour. After forty- eight hours, if there is no vomiting, 
milk and soda and barley-water can be freely given. A little plasmon 



208 POSTOPERATIVE TREATMENT. 

dissolved in the tea or beef-tea or barley-water adds considerably to the 
nutritive value of the fluid. Light custard pudding is usually given 
on the third day, fish on the fourth, and chicken on the fifth, after which 
the diet becomes normal. 

" The bowels are not disturbed before the third day, and then only 
by enema, unless there is vomiting or distention; and in case of either 
of these complications, a grain of calomel is administered and followed 
by two ounces of Apenta water even- two hours until it acts or until 
flatus passes freely, this being at times helped by the rectal tube or by 
a turpentine enema. Morphia is avoided after all my abdominal opera- 
tions, as it tends to paralyze the intestines and leads to an accumulation 
of flatus. I believe that abstention from the use of morphia is a great 
feature in the success of abdominal surgery, just as I feel sure that 
in the past it has killed many patients who would otherwise have done 
weh. 

" If a sedative is needed, ten grains of aspirin will be found useful, 
and this can be repeated in two hours if required. In case of vomit- 
ing being troublesome or epigastric distention persisting, gastric lavage 
will be found useful, and when the stomach is emptied, a dose of Apenta 
water may be left in it to incite peristalsis. Under these circumstances, 
no food or fluid is allowed by mouth, but plenty of fluid in the shape of 
normal saline is given by rectum. 

"As a rule, recover}' is uneventful, and, for the most part, after-treat- 
ment is negative. The stitches are removed on the eighth day, and the 
tube generally comes away about the same time; the wound generally 
will have healed by first intention, and the spot where the tube was, 
heals by granulation. The dressings are of the simplest — sterilized 
gauze and sterilized wool being employed as a rule, double cyanide 
gauze being sometimes used next to the wound/' 

ABSCESS OF THE LIVER. 

Postoperative Treatment. — The postoperative procedure suggested 
by Thomas L. Rhoades, U. S. A., has proved of such marked satis- 
faction in our hands that we give in detail his method of after-treatment, 
as well as that portion of the technic essential to a proper understanding 
of the same. 

The liver being exposed, taking for granted that no adhesions exist 
between it and the diaphragm, narrow strips of sterile gauze are packed 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 20Q 

snugly all around the incision through the diaphragm, and between 
it and the upper surface of the liver, thus walling off the peritoneal 
cavity. No attempt is made to suture the nonadherent liver to the 
diaphragm, for the gland is too friable to retain sutures of any material, 
and in the several cases in which this was tried all the sutures tore 
through the tissue immediately on a slight amount of tension being used 
to approximate the two surfaces. 

That part of the liver is now exposed for operation, and bounded 
by the gauze strips, should be as low down as the location of the abscess 
will permit, to allow for subsequent liver contraction and the relative 
change of surface levels — a consideration in the final stage of drainage. 
The liver is incised with a knife, a closed clamp is pushed through the 
intervening structure into the abscess, is opened, and withdrawn. The 
patient is turned gently on his back to facilitate the- flow of pus, and 
when this has ceased, the cavity is examined and cleansed. Strips of 
gauze and a firm drainage-tube of large caliber are passed into the 
cavity, the tube being anchored on the skin-surface by a stitch, and 
knots of white and black sterile silk are used to mark the ends of the 
gauze strips passing into the liver, and those packed around the open- 
ing through the diaphragm. These ends are brought out of the wound 
at the posterior angle, alongside the rubber tube; several additional 
strips are packed in the wound superficially to retain an opening through 
the chest wall at least 5 cm. in diameter, and the remainder of the skin 
flap is sutured in position with silkw T orm-gut. The dressing will con- 
sist of two parts: A single pad of sterile gauze for the exploratory 
incision, covered over with sterilized guttapercha or oiled silk, the edges 
of wiiich overlap the gauze pad and become glued to the skin; and a 
generous arrangement of gauze and cotton pads built around and over 
the ends of the gauze drains and tube. A single broad binder from 
axilla to pelvis retains the whole in position. Time for both oper- 
ations — exploration and rib resection — forty-five minutes. 

After-treatment. — Judicious management of the postoperative 
period is most important, for on it will depend the ultimate outcome 
of the case. Individual methods of handling conditions differ widely, 
and that surgeon will secure the best results who adheres to methods, 
medicaments, and food-stuffs found most reliable under similar con- 
ditions in years of experience. 

My general plan is to administer morphin sulfate J grain and atropin 
sulfate 2lnr grain to the patient after consciousness has returned, to 
14 



2IO POSTOPERATIVE TREATMENT. 

allay pain and combat shock. If much blood was lost during the oper- 
ation, saline transfusion will have been given on the table; and if shock 
is deep, application of dry heat and an enema of 250 c.c. of hot coffee 
will control it. Hot tea, which is acceptable to the stomach and dis- 
sipates the ether more rapidly, is sipped about four hours after returning 
to bed. Later in the day and on succeeding days, especially if there 
is nausea or vomiting, iced ginger ale, lemonade, albumen- water, or a 
sherry cobbler may be taken as beverages. 

Free discharge will necessitate change of dressings about eight hours 
after operation, at which time the entire dressing is removed and clean 
gauze and cotton are reapplied, the patient remaining in bed. On 
the following five days the dressing is changed twice a day, the patient 
being lifted into a rolling litter and taken to an adjoining room each 
time, so that bed-linen and mattress can be changed and aired. On 
these occasions the new dressing is applied after washing off the skin- 
surface with water and alcohol, but the drainage is not disturbed. 
During the first six days, the time when fibrous adhesions are forming 
between the surfaces around the gauze packing, the patient is kept 
mildly under the influence of an opiate — either morphin sulfate, -J- 
grain, or Dover powder, \ grain, morning and afternoon — to promote 
restfulness and allay pain, but not in sufficiently large dose to act as a 
hypnotic. Effects on the nervous system in each case will determine 
the dosage. On the sixth day adhesions will have formed, and the 
gauze drainage and rubber tube will be surrounded by a fibrinous ex- 
udate and lymph, which, on removal of the drains, will have established 
a secure pathway from skin-surface to abscess-cavity. The gauze 
strips and rubber tube can therefore be removed with safety. The 
ends of the gauze projecting from the wound are clamped on forceps, 
and by twisting and tugging are removed in separate pieces. The tube 
is likewise withdrawn. With the aid of a stout, bent glass tube having 
a lumen 0.5 cm. in diameter, the cavity is irrigated with warm sterile 
water until the flow returns clear. A new rubber tube, similar to the 
one removed, is carried into the cavity, the depth of insertion being 
regulated by a sterilized safety-pin transfixing its external end. Strips 
of sterile gauze are packed around the tube down to the abscess- cavity, 
dressings are applied, and the patient is returned to bed. This process 
is continued on each successive day, a clean tube and new strips for 
drainage being inserted after irrigation, until there is no further evidence 
of pus; all packing and drainage are then discarded, and the sinus is 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 211 

allowed to close. The patient is permitted to sit on a rolling chair in a 
reclining posture after the second week, and during the last days of 
local treatment will be walking about — providing, of course, systemic 
conditions are favorable. 

Anemic patients about ten days after operation are given thrice 
daily on an empty stomach 30 c.c. of pure olive oil in a wineglass, into 
the bottom of which is squeezed 10 c.c. of lemon- juice. The oil should 
be of pure variety, the product of the press when the fruit is nearly 
ripened, so as to lessen the tendency to nausea. This amount can be 
increased to 60 c.c. or 90 c.c. three times daily in the course of a week, 
without causing any gastric disturbance, which dose is then continued 
for weeks until all evidence of dysentery has disappeared, a time which 
is necessarily variable. Patients soon acquire a taste for the oil, and 
those to whom is was distasteful at the onset of the treatment have later 
been seen to crave it. Under its influence they gain rapidly in weight, 
color, and vigor. Patients reduced to the neighborhood of 90 pounds 
and who were bedfast for months, have increased in weight from 40 
to 50 pounds in six weeks' time, taking daily walks in the open air. 
The effect on the intestinal dejections is the most notable feature of 
the treatment. The oil acts beneficially principally by stimulating the 
portal circulation, increases the flow of bile, restores a natural diges- 
tive agent and antiseptic to the intestinal canal, and, combined with 
the bile, protects and promotes healing of the ulcers. 

Feeding is an equally important matter, and at the beginning of 
convalescence, a proper dietary must be selected which will build up 
the patient, increase his powers of resistance, and while generous in 
quantity must not overwhelm his digestive powers. Milk and all 
articles of food prepared with milk (soups, gruels, etc.) are proscribed. 
The diet on which these patients thrive best, and gain most rapidly, 
is one of solid food, given in conjunction with the administration of 
olive oil. Salads and shellfish are usually most grateful, and, together 
with minced meats and well cooked vegetables, constitute the most 
desirable dietary. 

HEPATIC TOXEMIA OR ACUTE FATTY DEGENERATION 

OF THE LIVER. 

Is a rare occurrence, but is now recognized as a possible postanes- 
thetic complication. Bevan-Favill (" Jour. Am. M. Ass.," Vol. xi, No. 5), 
report an interesting case, with a collection from literature of a number 



212 POSTOPERATIVE TREATMENT. 

of interesting cases, which they descibe in detail. Children from one 
to ten years of age seem to be the most susceptible. The symptoms 
appear in from thirty- six to sixty hours following, as a rule, chloro- 
form anesthesia. 

Brewer describes the three characteristic symptoms, as sweetish 
odor of the breath, delirium and rapidly fatal coma. Another symp- 
tom is that of air hunger, described by Kussmaul, evidenced by deep 
breathing and a bright red color of the mucous membranes, Cheyne- 
Stokes respiration and cold extremities. 

Brackett, Stone and Low describe the following symptoms : Vomiting 
associated with collapse ; a very weak and rapid pulse ; an absence of fever 
until just before death; cyanosis in the fatal cases, causing extreme 
dyspnea; apathy and stupor alternating with periods of restlessness, at 
first, but in the fatal cases gradually deepening into coma and death; 
the presence of acetone in the breath and urine, and icterus are often 
marked symptoms. 

Stocker describes the symptoms in his case as follows : The morning 
of the second day after the operation the patient, who had been doing 
well, became very restless, threw herself about in the bed, but her mind 
was at first clear. The next day coma and death. 

Guthrie says of symptoms: 

After recovery from the immediate effects of the chloroform there 
was an interval of a few hours, at the end of which the child uttered 
piercing cries at short intervals, disturbing the whole building by its 
shrieks, grinding its teeth, tossing, struggling and requiring constant 
attention, lest dressings be torn off or fractured bones displaced. The 
pupils were dilated, sometimes unequally, the face being flushed or 
pale, with a look of wild terror and anxiety. Consciousness was lost 
early and never regained; sometimes there were intervals in which the 
child would be dull and apathetic, but would answer rationally when 
addressed, and usually denied being in pain. Vomiting was a marked 
feature. It was copious, frequent, persistent and the vomited matter 
resembled the dregs of beef-tea. 

Possible predisposing or accessory causes are, alcohol, lead, car- 
bolic acid, mercurial, and iodoform intoxication. Other causes are 
homesickness, fright, change of food (Brackett, Stone and Low), intes- 
tinal fermentation and putrefaction; extensive fatty changes associated 
with infantile paralysis; starvation; sepsis. In pregnancy, in the pres- 
ence of a dead fetus; the existence of a gangrenous mass, diabetes, 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 213 

carcinoma, anemic states from any cause and hemorrhage are also to be 
considered. 

The possibility of the development of hepatic toxemia makes chloro- 
form distinctly contraindicated in those cases in which there exist the 
conditions which seem to favor its development, i.e., diabetes, sepsis, 
starvation, hemorrhage; the presence of intoxication from dead material; 
the presence of fatty degenerations, as already cited after infantile 
paralysis, and lesions of the liver. The susceptibility of children to 
this hepatic toxemia must be recognized. That chloroform is capable of 
producing these serious late poisonous effects is a strong argument 
against its employment, and an argument in favor of the more general 
use of ether. 

Treatment. — The treatment is wholly symptomatic. Lavage of the 
stomach, hypodermatics of morphin and hyoscin with adrenalin and 
other heart stimulants, with possible hypodermoclysis, are called for 
early. 

GASTROTOMY, GASTROSTOMY, PYLORECTOMY. 

General Remarks. — Many forms of incision have been advised 
and carried out. Some have employed an incision in the median line, 
others a vertical incision in the left linea semilunaris. Sedillot used a 
cross-cut below the xiphoid cartilage. Howse prefers a vertical incis- 
ion in the sheath of the rectus, a little to the inner side of its outer 
border. The vertical fibers of the rectus are exposed and are separated 
(not cut) with the handle of the scalpel. The posterior part of the 
sheath is thus reached. It is divided vertically, and the abdominal 
cavity opened. The incision has the disadvantage of bringing the 
wound area somewhat closer to the pyloric region. In carrying out 
the incision it should be remembered that, owing to the emaciation of 
the patient and the sunken condition of the abdomen, the part of the 
abdomen attacked is — as the patient lies upon the back — almost ver- 
tical. The integument, after passing over the margin of the ribs, turns 
suddenly backward toward the spine, following the sunken abdominal 
wall. 

In gastrostomy several methods have been " invented" of fixing 
the pouch of stomach obliquely through the abdominal wall and then 
opening the extreme upper end of this tubular process, a catheter being 
secured in the usual way. They cannot be described here, but the 
postoperative treatment applies to all. The many different methods 



214 POSTOPERATIVE TREATMENT. 

adopted of feeding the patient only serve to emphasize the fact that 
no rigid rule can be adhered to, and that this factor in the after-treat- 
ment must be modified according to the particular circumstances of 
each case. 

Feeding of the Patient and After-treatment.— The amount of food 
introduced on the occasion when the stomach is opened must depend 
upon the patient's condition. If no food has been swallowed for a 
considerable period, it will suffice at first to introduce only a few drams 
of milk mixed with a little brandy. The quantity can be gradually 
increased. If, however, the patient has been able to take some food 
through the gullet up to the time of the operation, his first meal may 
consist of from two to four ounces of a mixture of milk, egg, and brandy. 
This is slowly poured in through the funnel, the guaze covering of which 
prevents any semisolid particles from entering and blocking the tube. 
A pad of soft gauze packed around the aperture in the stomach will 
absorb any fluid which may escape. As a matter of fact, however, such 
escape is very seldom to be anticipated. 

After the feeding the tube is left in place. It is secured to the ribs 
in the form of a coil by means of strips of plaster. Its end is left open, 
and serves to afford escape to any fluid which the stomach might attempt 
to reject. This open end is received by a pad of absorbent wool or 
the tube may be closed in the intervals of feeding by light clamp. The 
skin around the margin of the "stoma" is kept clean and dry, is smeared 
with lanolin, and well dusted with sodium bicarbonate. 

The feeding should be repeated frequently; the amount given is 
slowly increased, but the quantity administered each time should be 
small. 

The diet will consist of milk, eggs, beef-tea, soups, tea, cocoa, certain 
prepared foods, and a proper allowance of water. All food admin- 
istered should be of the temperature of the body. As time advances 
more food may be given, but at less frequent intervals. The fistula 
may in process of time become enlarged, and then very finely minced 
meat and pulped vegetables may be introduced into the stomach by 
means of a suitable syringe. On the other hand, a tendency to con- 
tract is sometimes shown, and must be overcome by occasional dilation 
with a seatangle tent. The patient's own feelings afford the best guide- 
to the value of certain foods and the amount and mode of their admin- 
istration. It will often be found that the patient after gastrostomy is 
able to swallow with greater ease for a time. 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 215 

Leakage of gastric juice and regurgitation of food arc often due 
to the stomach having been opened too near to the pylorus. The 
patient who is the subject of such trouble should be fed in the recumbent 
position, and lying upon the left side. Leakage may also be due to 
the gastric opening having been made too large. 

The irritation produced by the escape of gastric juice is best met 
by constant attention to cleanliness, by the very frequent changing of 
dry absorbent pads, and by the liberal powdering of the part with 
sodium bicarbonate. 

OPERATIONS UPON THE INTESTINES AND USE OF THE 
MURPHY BUTTON. (MURPHY.) 

The Murphy button should be used only for end-to-end or end-to- 
side approximation in the small intestines, an end-to-side or side-to- 
side approximation of the large intestines, as well as side-to side approx- 
imation of the jejunum or duodenum to the stomach. For a gastroen- 
terostomy Murphy prefers the posterior operation and the oblong button. 
In the stomach it prevents subsequent closure. One of the important 
factors in either method of approximation, particularly in acute intes- 
tinal obstruction, is to remove a number of inches or even feet of the 
bowel on the proximal side of the occlusion. The bowel in this con- 
dition is often infiltrated, ulcerated, or bordering on necrosis, and unless 
a sufficient extent is resected, there will be a failure of union, no matter 
what method is employed. In acute obstruction the contents of the 
bowel above the obstruction should be allowed to flow out at the time 
of the operation. When much work or manipulation is done in the 
abdominal cavity, particularly with bullet wounds, drainage should 
be instituted and the patient placed in a sitting position. The abdomen 
should never be flushed. Excess of sponging, packing, and manipulation 
of the intestines increases the danger of shock and infection. 

After the use of the Murphy button liquid nourishment is administered 
eight hours after the patient recovers from the effects of anesthesia. 
This nourishment does not include milk; and no solid food is allowed 
until the button passes. Morphin is practically never used after lapar- 
otomy in Murphy's work. In a general way the after-treatment 
corresponds with that employed after gastroenterostomy, with a difference 
that food is given by mouth a little earlier, and that active cathartics 
are not given until the button is passed. If the colon is involved in the 



2l6 



POSTOPERATIVE TREATMENT. 





Fig. 69. 



operation, predigested foods are given by mouth from the third day on, 
but nourishment by enema is not employed. One can easily choose 
a predigested food which is absorbed almost entirely from the stomach, 
which will sustain the patient until the union between the united ends 
of the intestine is sufficiently safe to make use of a general diet. Ordi- 
narily, firm union ex- 
ists after the third day, 
but many patients in 
whom these operations 
are indicated are 
much reduced in 
strength, and conse- 
quently their tissues 
do not heal so rapidly ; 
and in such conditions 
alcoholic stimulants 
are imperative. 

The length of time 
the button may be re- 
tained in the intestinal 
canal varies greatly. 
It usually passes in 
seven to fourteen days. 
In some cases several 
weeks may have 
elapsed before it ap- 
pears in the rectum. 
Its presence and posi- 
tion in the abdomen 
can, of course, be 
ascertained by ski- 
agraphy. When the 
button remains in the 
intestine, unless it is 
giving manifestations 
of irritation, which it 
rarely does, it should never be disturbed. It can usually be found 
situated in the rectum, just above the internal sphincter, after seven to 
ten days, and when it can be felt by digital examination it is extracted 




Fig. 70 




Fig. 71. 
Figs. 69 to 71. — End-to-end Approximation with 
Murphy Button held in Position by Purse-string 
Sutures. — (Binnie, after DaCosta.) 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 217 

with forceps. Should symptoms of irritation, indicated by a rise of 
temperature, tympanites, abdominal pain, etc., supervene after fourteen 
or twenty-one days, a skiagraph should be taken and if the button has 
passed the point of adjustment or approximation a laxative of castor 
oil or magnesium sulfate may be safely given, but if the button remains 
at the point of situ and symptoms of irritation increase, a laparotomy 
may be necessary, and if by gentle taxis the button cannot be displaced it 
should be removed by incision or possibly if gut is contracted a second 
anastomosis may be required. 

COLOSTOMY. 

Considerations of Technic. — The operation of colostomy for the 
purpose of establishing an artificial anus is performed in two ways. 
The most common practice is as follows: The colon is drawn out 
through an incision in the abdominal wall, its mesentery split, and a 
flap of skin is cut and drawn through the slit in the mesentery and sutured 
in place. The upper segment of the intestine is then drawn outward 
and the lower segment placed inward, and the skin- flap drawn through 
the opening in the mesentery. In this manner the upper segment is 
bent over the outer edge of the abdominal wall and underneath the 
skin-flap; consequently after healing has taken place the application 
of a pad over this part will cause the skin-flap to act like a valve and 
prevent the voluntary evacuation of the bowels. In order to prevent 
protrusion, several stitches are inserted, attaching the intestine to the 
skin. The loop of the intestine is not opened until adhesions have 
formed, unless this is necessary on account of complete obstruction, in 
which case the wound is carefully protected and a large rubber tube 
covering a short glass tube is inserted into the upper segment and 
securely fastened by means of a strong purse-string suture. This will 
compel the contents of the intestines to pass out through the tube which 
passes through the center of the dressings without soiling the wound. 
If immediate opening of the intestine is not necessary, the part should 
be covered with sterile gauze held in place by means of broad adhesive 
strips and abdominal bandages. After three to five days when adhesions 
have thoroughly formed the intestine may be opened, and evacuation 
of the bowel can now occur without interference with the healing of 
the wound. 

Another method is to draw the intestine purposely through a thick 



2l8 



POSTOPERATIVE TREATMENT. 



part of the abdominal wall by bringing it out obliquely rather than 
directly through the tissues, by choosing the muscular part so that the 
muscles by tension and contraction may keep the gut closed, and only 
give under the pressure and force exerted by the peristaltic contraction 
of the intestine. The intestine is now carefully sutured in position 
and allowed to granulate for forty- eight to seventy- two hours, after 
which delay the bowel is opened transversely to its long axis so that 







A 



•%5%, ; 






Fig. 72. — Macewen's Sutures to Draw the Conjoined Tendons to Poupart's 

Ligament. — (Moullin.) 



the upper end shall evacuate its contents externally directly through 
the opening. If the artificial anus is to be but temporary, it is prob- 
ably best to make the opening in the long axis of the gut rather than 
transversely. Some surgeons — Hartman and others — do not suture 
the intestine at all, but merely pull out the gut, packing a piece of iodo- 



I.IVKR, AND INTESTINES. 219 

form gauze carefully around it and over both ends, leaving it there for 
eight hours. 

After-treatment. — Ochsner states that until the protruding loop 
has been cut only hot water and small quantities of predigested food 
are given by mouth. After this general liquids, and after a week light 
diet, are given. 

This operation is usually performed in old persons greatly reduced 
in strength, and these do not bear lying quietly in bed. It is conse- 
quently best to permit them to occupy a semisitting position within a 
day or two after the operation and to leave the bed within a week or 
ten days later. After the intestine has been opened a cathartic, prefer- 
ably castor oil, should be given, and this should be followed by several 
enemas in order to remove fecal accumulations which frequently exist 
in large quantities above the constriction, even if a diligent attempt 
has been made to evacuate the bowels before operation. Frequently 
the lower segment contains many of these masses, which can usually 
be removed by irrigation, but may occasionally require a blunt scoop 
for their removal. It is well to examine the opening by inserting the 
ringer within the lumen of the intestine through the abdominal wall, 
because occasionally not sufficient space has been allowed for the evacu- 
ation of the bowels and the free passage of gas. This can be remedied 
readily by a slight incision. 

These patients should be instructed to regulate their diet so as to 
avoid constipation, and then to take a simple cleansing enema once 
a day to insure a free evacuation of the bowels. Thus they can usually 
be entirely free from any annoyance because of the artificial anus. A 
small pad of cotton should be worn over the opening, held in place by 
a simple abdominal bandage. In case there is any annoyance from 
escaping feces a substantial pad may be held in place over the opening 
by means of an elastic bandage which will compress the intestine under- 
neath the skin-flap. 

If there is not enough force in the colon to effect an evacuation, it is 
sometimes best to insert a large rectal tube after giving the enema and 
to effect the evacuation through this. 

Postoperative Treatment as Recommended by Sir Frederick 
Treves. — When the symptoms are not urgent, the operation of colos- 
tomy is usually carried out in two stages {colostomy a deux temps). 
The bowel is fixed to the skin by numerous superficial sutures. Care 
should be taken that no suture extends through the mucous lining of 



220 POSTOPERATIVE TREATMENT. 

the bowel. The part is well dusted with iodoform, and after an interval 
of thirty-six to forty-eight hours the operation is completed by opening 
the colon. 

After-treatment. — The actual wound is dusted with iodoform, 
and all the skin around is well covered with lanolin. A large pad of 
absorbent wool is placed over the artificial opening, and retained by 
means of a many-tailed bandage. So long as there is a copious escape 
of fecal matter no bandage should be applied. The pad of wool must 
be changed as often as it is soiled, and the exclusive attention of one 
nurse should be occupied in keeping the patient always clean. 

When the discharge is very free, a pad of loose "tenax," covered with 
a layer of wool, will be found to be more convenient. The main feature 
in the nursing is that the part must be kept dry. The skin should not 
be rubbed clean, but should be cleansed by a stream of warm water, 
which is received in a kidney- shaped tray. This method involves 
no more trouble and no more time than the patting and rubbing process 
which is carried out with innumerable pledgets of cotton- wool. After 
each washing the skin is very gently dried, and is once more covered 
with lanolin. If the wound were to need washing every fifteen minutes 
during the first day or so, it would certainly be better to do so than to 
allow a freshly united incision to remain for an hour or more poulticed 
with fecal matter. 

During the first few days the patient should keep very quiet, should 
lie upon the back, or, if the position be altered at all, should turn over 
toward the wounded side. The attachments of the gut will be dragged 
upon if the patient lie upon the sound side. The discharge of fecal 
matter from the bowel may be delayed for hours or even for days. 
The opening, as already stated, is at first very small; and if it suffices, 
well and good. If, however, hard scybala have to escape, then the 
opening must be in due course enlarged. An aperient given on the 
fourth or fifth day after the operation has often an excellent effect. 

Prolapse of the gut at the artificial opening is, so far as my expe- 
rience goes, but rarely met. A preliminary small opening in the gut, 
primary healing, and the maintenance of a healthy condition of the 
mucous membrane appear to be the main factors which assist in pre- 
venting this complication. The skin around the artificial anus may 
become very raw and inflamed. This is especially likely to be the case 
when the fistula is established near a malignant growth, as when the 
colon on the right side is opened. In these circumstances a frequent 



OPERATIONS ON STOMACH, 1 I\I K, AND INTESTINES. 221 

washing-out of the bowel, and the most scrupulous attention to the 
cleanliness of the part, will effect much. 

Properly shaped pieces of lint soaked in oil may prevent some of the 
fecal matter from running over the skin, but no contrivance that I have 
as yet seen has prevented it entirely. The disturbing symptoms pro- 
duced by the presence of fecal matter in the colon below the artificial 
opening may be relieved by the systematic washing-out of that part 
of the bowel, and by the subsequent closure, if need be, of its upper 
extremity. 

The diet in these cases should be spare and nourishing, and of 
such a kind as to leave the least possible residue in the intestine. The 
consumption of milk in considerable quantity appears to encourage 
the formation of scybala. A liberal amount of vegetable matter should 
be a feature in the diet. 

After the wound has healed and the recovery from the operation 
is complete, the patient may be furnished with a simple belt which 
will permit a pad of wool or some folds of linen to be held in place 
when the patient is moving about. The simpler the belt, the better; 
and it must be so constructed as to be readily unfastened. The various 
plugs, cups, bags, and pessaries which have been devised for the use of 
patients after colostomy are, so far as I have seen, more or less useless. 
After a short trial they are usually abandoned for some simple arrange- 
ment of cloths or pads which the patients have themselves devised. 

Colostomy for Acute Obstruction. — In cases of acute obstruction 
of the bowels when the patient is greatly exhausted we have found 
the method of rapid or temporary colostomy, as devised or practised 
by Franklin H. Martin, to be not only very simple, but highly satis- 
factory, affording rapid relief to the patient. A small abdominal 
incision is made under local anesthesia. A loop of distended bowel is 
pulled through and out; a piece of gauze is passed between the skin 
and the bowel through its mesentery. A small incision is made into 
the bowel and a portion of the Murphy button hastily inserted and 
attached to the intestinal wall. The other or outer end of the button, 
having been previously covered by a piece of rubber tubing, is rapidly 
pushed home, the discharges from the bowel being conveyed into a 
pus-pan or vehicle. Since much time is usually lost in an effort to 
determine which is the upper or lower end of the bowel, no effort is 
made to determine this question at this time. Later, when the button 
comes away, the direction of bowel movement can be easily determined, 



222 POSTOPERATIVE TREATMENT. 

and by this time the patient, having recovered strength, a laparotomy 
can be made with safety, and the obstruction removed if present, or 
an end-to-end approximation may be made and the bowel dropped 
into the abdominal cavity. This operation is essentially an emergency 
one. 

INTESTINAL OBSTRUCTION. 

Concerning after-treatment Nicholas Senn says : Uniform equable 
support of the abdomen, by strapping and bandages over the anti- 
septic absorbent dressing, furnishes efficient support to the distended 
abdominal walls and the paretic intestines, and is not only grateful 
to the patient, but is an important aid in relieving the distress due to 
distention and peristalsis. In all operations for intestinal obstruction 
efforts should be made to empty the bowel, not only at the seat of obstruc- 
tion, but so far as it can be done throughout, as such immediate evacua- 
tion constitutes one of the elements of success. 

J. Greig Smith states that "no case of operation for intestinal obstruc- 
tion is properly concluded until the distended bowels are relieved of 
their contents." One of the most favorable symptoms after a successful 
operation for intestinal obstruction is a spontaneous action of the bowels, 
as it not only proves the permeability of the intestinal canal, but is also 
an evidence that peristaltic action has been restored. The retention 
of fecal material in the distended paretic intestines after operation for 
intestinal obstruction is a condition that not only retards recovery, but 
is in itself a grave source of danger. Through the sympathetic nerves 
the distended intestine exerts a most depressing effect on the cere- 
brospinal centers, while the putrefactive changes that are constantly 
going on in the stagnant intestinal contents must be a constant source 
of intoxication, and, at the same time, the migration of septic micro- 
organisms through the paretic walls threatens life from septic peritonitis. 

Symptoms of shock are met by the administration of strychnin sub- 
cutaneously, stimulants by the rectum, intravenous or subcutaneous 
saline infusions, and stimulation of the peripheral circulation by dry 
heat applied to the surface of the trunk and extremities. Mr. Tait 
has taught us the value of cathartics in the prevention of peritonitis 
after abdominal operations. Would it not be rational to follow his 
example in the after-treatment of operations for intestinal obstruction ? 
Surgeons have repeatedly made the observation that the paretic intes- 
tine above the seat of obstruction will respond slowly but surely to 



OPERATIONS ON STOMACH, LIVER, AND INTESTINES. 223 

mechanical irritation, and it is logical to conclude that the same effect 
would be produced by the administration of a brisk saline cathartic. 
Dangerous as the use of cathartics necessarily must be before the obstruc- 
tion is removed, so beneficial may their judicious employment be after 
the continuity of the intestinal canal has been restored by operative 
treatment. 

Feeding, etc. — Thirst is quenched by sips of hot water, fragments 
of ice, and saline rectal enemas. Stomach-feeding is absolutely con- 
traindicated for the first forty-eight or seventy-two hours, during which 
time rectal alimentation is relied upon exclusively. Absolute rest in 
the recumbent position must be enforced until the visceral and abdom- 
inal wounds have healed. The administration of copious laxative 
enemas is permissible for the purpose of assisting the saline cathartics 
to restore peristalsis, provided the seat of strangulation was above the 
ileocecal valve. 

Postoperative Enterostomy. — Enterostomy for the purpose of feed- 
ing, or in cases of intestinal paresis, is to be recommended especially for 
temporary use, and it should be resorted to under none but urgent 
indications, the disadvantages of an intestinal fistula being manifest. 
The operation requires but a few minutes and is readily performed 
under local anesthesia. 

The techxic of the operation varies somewhat, depending upon 
whether it is primary or secondary to another operation, or whether 
the fistula is to be used for feeding alone or for drainage as well. If 
for the purpose of feeding only, the method introduced by Witzel for 
gastrostomy is perhaps the one to be chosen. R. Follis, Resident 
Surgeon of the Johns Hopkins Hospital, has reported a method for the 
production of a temporary intestinal fistula which we believe offers 
an advantage over any other with which we are familiar, in that the 
intestines may be opened immediately with less risk of soiling the peri- 
toneum. These fistulas generally close spontaneously. 

We have generally proceeded as follows : The selected loop of bowel 
is brought out and iodoform gauze is packed around it to wall it off from 
the general peritoneal cavity. This loop may be opened immediately, 
or if the patient's condition admits of delay, sufficient time may be 
allowed for the formation of protective adhesions. After the opening 
has been made a rectal tube is inserted, first in one direction and then 
in the other, and may usually be passed several feet either way. This 
will allow the escape of gas and feces from the distended bowel, and 



224 POSTOPERATIVE TREATMENT. 

through it, when necessary, a considerable segment of the intestine may 
be irrigated. So soon as the intestine has been opened and the tube 
is inserted we generally inject a quantity of salt solution in both direc- 
tions, and by watching can usually determine which is the distal portion. 
After the distal segment has been determined, one can begin at once 
the administration of stimulating or nutritive enemas through the fistula. 
The amount of fluid that can be given in twenty-four hours and retained 
is surprisingly large. Water or coffee infusion, peptonized milk, eggs, 
and prepared foods in any desirable quantity can, through the tube, 
be placed in the intestine several feet from the opening, and by gravity 
or hydraulic pressure be forced onward into a collapsed, atonic bowel. 
Purgatives, such as castor oil, salts, croton oil, calomel, or, in fact, 
anything that the normal stomach will tolerate, seem to be well borne. 
Generally in favorable cases peristalsis becomes quickly reestablished, 
and the fistula closes spontaneously or can be closed by operation. 

In abdominal operations in which the immediate necessity for the 
establishment of a fistula does not exist, and yet in which the operator 
has reason to fear that the operation may later become indicated, it is 
well before closing the abdomen to determine the loop of intestine in 
which the opening can be most advantageously made. This loop should 
be fixed by the gauze packing in order that it may be readily accessible 
for subsequent manipulation. Guide sutures should be inserted into 
the bowel wall at the point to be opened. These may be taken out 
without harm at any time later and the gauze removed, if it is found 
unnecessary to incise the bowel. 

Postoperative intestinal fistula once established should be 
looked upon more as a mouth than an anus. It should be used for 
irrigation of the intestinal canal, for the nourishment of the patient, 
and for the introduction of cathartics. We have often noticed that 
food introduced into the intestinal canal through the fistula had of itself 
a stimulating effect upon the peristalsis. 



CHAPTER XI. 

LAPAROTOMY AND OPERATIONS UPON 
THE ABDOMEN. 



CHAPTER XL 
LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 

Postoperative Treatment of Operations Upon the Abdomen. — 

In all laparotomies whether the operation is to be on the stomach and 
intestinal tract, uterus, or ovaries, the stomach and intestines must be 
emptied, the former by means of lavage, the latter by laxatives. As 
laxatives increase the number of bacteria, they should not be given later 
than two days before the operation. The food must be such as will 
not result in the formation of fecal matter. Soups, vegetable or 
animal, gruels, but no milk, with an abundance of fluids, are the usual 
routine. Two days before the operation betanaphthol bismuth or 
acetozone should be given, to limit as far as possible the fermentative 
changes in the intestinal contents. When the diet is very limited, opium 
should be given. 

Immediately following all laparotomies, and usually before the pa- 
tient is removed from the operating table, if there has been any con- 
siderable loss of blood, or if the patient be apparently delicate in nature 
or of neurotic temperament, a high rectal enema of normal salt solution 
should be administered, the solution being at a temperature of 108 
to no° F. If there seems to be a lack of tone or a general depressed 
condition, hypodermatic injections of nitroglycerin, strychnin, and digi- 
talin should be promptly given. 

Gruzdeff has long advocated copious flushing of the abdominal 
cavity with saline solution before closing it after a laparotomy. In 
28 cases in which the abdomen was treated by the dry method there 
were 3 deaths, while only one patient died in the 72 cases in which he 
followed his method of irrigation, and this fatality was due to other 
causes. He prefers Locke's solution for the purpose, as more nearly 
approximating the composition of the blood-plasma, and pours it into 
the abdomen three or four times, swabbing out the cavity each time 
with gauze sponges, and finally leaving a large amount in the abdomen 
after it is sutured. He thinks by this means the abdominal cavity is 
not only cleaned, but the germs that may have found their way in dur- 

227 



228 POSTOPERATIVE TREATMENT. 

ing the operation are washed out and the phagocytes are stimulated 
to more energetic action. A still further advantage is that the pressure 
in the abdomen is maintained by the fluid left behind, and it does not 
tend to collapse after the removal of large tumors. If symptoms of 
pronounced shock are present, the treatment should be energetic, as 
heretofore described. (See page 89.) Patients who are allowed to 
go for several hours with a subnormal temperature and high pulse are 
with great difficulty restored (Martin). In all aseptic cases the wound 
itself requires little or no attention for several days, and the dressings 
about the wound should not be disturbed unless symptoms of infection 
supervene, as announced by rising temperature, high pulse-rate, and 
general restlessness. After nine to fourteen days the wound should be 
carefully examined and the stitches removed, after which small strips 
of sterile adhesive plaster should be applied to support and prevent 
spreading of the scar. 

Care of the Bowels. — If flatus has not passed freely from the rectum 
in twelve hours by the simple employment of a rectal tube, a rectal enema 
of one ounce of magnesium sulfate, two ounces of glycerin, and three 
ounces of water should be given. If there is no bowel movement or if 
flatus is obdurate, one-half grain doses of calomel with or without sodium 
bicarbonate should be given every two hours until four to six doses are 
given, or until gas passes. If necessary, the calomel may be given 
alternately with dram doses of Rochelle salts, magnesium citrate or 
sulfate, in an ounce of water. If the stomach is very much irritated 
and will not tolerate calomel, after lavage with a solution of boric acid 
and before the stomach-tube is removed one ounce of castor oil should 
be administered. The cases are very few that will not yield , under 
these remedies. For more persistent cases or postoperative compli- 
cations the reader is referred to matter as heretofore described under 
special headings. 

Drainage. — When the glass drainage-tube is allowed to remain in 
the abdominal wound, it should be gently emptied in one hour by a 
syringe with a long rubber nozle. If the fluid is more than two or 
three drams, it should be dressed again in an hour, or if the fluid is 
less than a dram, the intervals between dressings should be increased. 
The tube is usually removed in twenty-four hours. If, however, after 
this time drainage seems necessary, a small piece of sterilized gauze 
may be inserted in place of the glass tube, and allowed to remain six to 
twelve hours, after which the wound is closed by ordinary sterile adhesive 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 229 

strips. If capillary gauze drainage has been employed instead of a 
glass tube, the protruding gauze should be abundantly covered with a 
pad of loose, fluffy gauze, and this should be changed as often as it be- 
comes saturated with fluid. If all drainage ceases in twelve to twenty- 
four hours as indicated by dry dressings, the gauze packing, if loose, 
may be removed. However, if drainage is free and the patient is nor- 
mal in condition, the gauze may remain forty-eight to sixty hours, 
and after its removal a loose gauze packing should be placed over the 
wound. 

Urine. — The patient should always be urged to pass urine voluntarily 
and the catheter should not be resorted to unless absolutely unavoidable. 

General Remarks. — So soon as possible after anesthesia hot water 
or hot tea in teaspoonful doses may be given as often as every fifteen 
minutes if the patient is extremely thirsty. If the stomach tolerates 
this, the quantity is increased to half an ounce every half-hour. When 
the patient cannot take hot water and complains of intense thirst, the 
nurse is instructed to let him rinse the mouth with cold water. After 
twelve hours, if the patient's condition is such as to demand nourish- 
ment, peptonoids or peptonized milk may be substituted; later, fluid 
nourishment, bouillon, broth, or thin gruel, may be substituted, so that 
by the third or fourth day the patient will be able to take the extracts 
of beef, shellfish broth, etc. Orange-juice and the juices of other ripe 
fruits are often greatly relished, and may be used in small and oft- 
repeated quantities. If stimulants are required, whisky is the best, or 
champagne may be used. If patients are unable to retain sufficient 
food by the stomach to nourish them properly, nutrient enemas as here- 
tofore described should be resorted to. Uncomplicated laparotomy cases 
after one week are permitted to sit up with a bed rest or allowed to be 
seated in a chair, but as a matter of routine, are not allowed to leave 
the hospital before the twelfth day. (Martin.) 

Laparotomy for Septic Conditions. — The surgeon frequently finds 
himself forced to operate after diffuse peritonitis from ruptured pus- 
tubes, appendix, or other sources of infection, and these cases should be 
classed by themselves, and so far as after-treatment is concerned, they 
belong to a different category from aseptic cases. How best to proceed 
under the circumstances to save an apparently hopeless case is tersely 
stated by Kocher as follows: "As soon as the abdominal cavity has 
been opened, the healthy regions of the abdomen should be shut off 
from the diseased parts on which the operation is to be carried out. 



230 POSTOPERATIVE TREATMENT. 

This should be done by packing with gauze. The introduction, through 
a sufficiently large external wound, of hot, sterile, soft gauze compresses, 
wrung out of an 8 percent salt solution, so as to shut off the field of opera- 
tion, insures against the harm which results, especially in septic cases, 
from the escape of gastrointestinal contents, bile, urine, or infective 
inflammatory products. 

"Avoid any antiseptic and any possibility of injury to the peritoneum 
by cooling and evaporation. Xo small praise is due to Tavel and his 
pupils for having demonstrated experimentally the nature of this dele- 
terious action, and for having rendered its avoidance possible. On 
the basis of their researches we were probably the first to employ (chiefly 
in laparotomies) only physiologic salt solution at the body-temperature 
and to keep all exposed peritoneal surfaces constantly moist and warm 
by irrigation, or by applying compresses and guttapercha tissue over 
them. Complete removal of even- source of infection and drainage of 
infected areas, combined with their isolation by tampons in the form 
of gauze strips impregnated with a fixed antiseptic, as recommended by 
Mikulicz, is necessary. As iodoform has such a toxic action on the 
peritoneum, xeroform or some other nontoxic antiseptic should be 
preferred. 

"Prevention of any collection of blood or effusion into the wound 
by most careful arrest of hemorrhage, no matter how long the time 
required to effect this, and by careful suture of even' injured surface 
of the peritoneum, is required. This is a most important point, and 
it was only when attention was paid to it that the intraperitoneal treat- 
ment of a uterine stump was rendered safe. 

"Tietze showed by. his excellent experiments that the omentum could 
be safely employed for covering over necrotic areas in the stomach or 
intestinal wall. Braun and Bennet even closed defects in the stomach 
with omentum only, which formed firm adhesions to the surrounding 
serous membrane. The inner surface of the omentum gradually be- 
comes covered over with epithelium which grows in from the edges 
of the opening. Careful suture of even- cut or tear in the peritoneum, 
and complete closure of the main wound in even- case when there is no 
question of draining away infective fluids, is essential.'' 

Position of Incisions. — The only incisions in the abdomen which 
can be regarded as normal are the median, the transverse in the upper 
part of the abdomen, and the oblique incision passing from above down- 
ward and inward in the lower part of the abdomen, because these incisions 



LAPAROTOMY AND OPERATIONS UPON Till'. ABDOMEN. 23I 

do not damage the muscles of the abdominal wall through their nerve- 
supply, and are in accordance with the principles which have been al- 
ready laid down for all the normal incisions of the body. The above 
normal incisions can be very well used in combination, as, for instance, 
in splenectomy, or for carcinoma of the lowest part of the sigmoid flexure, 
when to the median incision a transverse incision may be added, varying 
in length according to the requirements. Assmy, at Czerny's instiga- 
tion, showed that the longitudinal incisions through the middle of the 
rectus, which are preferred by many surgeons, cause atrophy of the 
median portion of the rectus if its motor nerves are interfered with. 

Laparotomy in Cases of Peritonitis. — When an exudate which can 
be demonstrated clinically has formed in the peritoneal cavity, the only 
certain way of preventing extension of the inflammatory effusion is 
early operation. When exploring the deeper parts in such conditions 
it is quite unnecessary to use any other than the normal incision with 
splitting of the muscles. 

According to McBurney's method, all circumscribed abscesses, 
both those with fluid contents and those in which there is merely a free 
inflammatory exudate, can in this way be thoroughly evacuated and 
drained through a small incision. Difficulty is first apparent in the 
treatment of peritonitis when numerous small or large abscesses sur- 
rounded by fibrous adhesions have formed in different parts of the 
peritoneal cavity. Many cases have been recorded of satisfactory re- 
sults in so-called diffuse peritonitis, which, however, were not diffuse in 
the sense that the whole peritoneal cavity up to the diaphragm was 
involved, but which represented merely encapsulated inflammations 
occupying a large area of the peritoneum. There is only one certain 
means of, dealing with such diffuse forms with numerous encapsulated 
foci of infection, and that is by prophylactic treatment. A circumscribed 
abscess may lead to multiple abscess-formation either by the spread of 
the infective material or by perforation, or, a priori, diffuse peritonitis 
with fluid exudate may lead to multiple suppurative areas by the pouring 
out of fibrin and the formation of adhesions. The only way to prevent 
this extension is to treat even- attack of inflammation at its commence- 
ment on surgical principles, i. e., to open and remove the infective mate- 
rial. In this respect the advocates of immediate operation in early 
cases of perforated appendicitis are undoubtedly right, as a definite 
percentage of the cases in which expectant treatment is employed in 
preference to immediate operation must be lost from peritonitis. When 



232 POSTOPERATIVE TREATMENT. 

an incision is at once made, as advocated by Bernays, Rehn, Deaver, 
and others, and the source of infection removed, although death cannot 
be avoided in every case, yet, as Bernays has proved, the results, if all 
the cases be taken into account, are better than those where expectant 
treatment is employed. 

In peritonitis which is diffuse from the onset, with a fluid exudate, 
it is quite justifiable, after the cause has been removed, to make a 
median incision and to irrigate the peritoneal cavity thoroughly with 
physiologic salt solution at the body-temperature, for as long a period 
as may be required. For diffuse peritonitis with multiple encapsulated 
abscesses, not only between the intestinal coils, but also between the 
liver, spleen, and diaphragm, a long laparotomy incision is indicated, 
so that free access may be gained to all abscesses. But such a long 
incision is attended with danger from shock, the result of injury to the 
hyperesthetic peritoneum; it reflexly inhibits or paralyzes the vaso- 
motor center, and, by a direct action on the abdominal vessels, increases 
the venous hyperemia in the abdomen, and with it secondary cerebral 
anemia. 

In severe cases it often becomes necessary to empty the intestines 
by washing them out thoroughly through an opening above and below 
in order to prevent absorption of toxic products from the intestines, 
and to keep them empty by the administration of magnesium sulfate. 
Further, after the operation, hyperemia of the abdominal organs should 
be reduced as much as possible by proper posturing of the patient, 
combined with the application of ice and compression to the abdomen. 
A matter of great importance in the treatment of peritonitis is to drain 
off all inflammatory products and infective material. For this purpose 
the insertion of one drainage-tube is not sufficient. Each area of sup- 
puration must be opened and drained. If this is done, it will be found 
unnecessary to irrigate in cases of diffuse multiple collections of pus, 
and the resulting shock is much less. 

Postoperative Laparotomy for Peritoneal or Intestinal Adhesions. 
— Lauenstein emphasized the good results which can often be obtained 
in cases of severe pain and spasms in the region of the digestive tract by 
opening the abdomen and simply separating adhesions which fix the 
viscera to some particular spot on the abdominal wall, or which link or 
bind them together. The importance of this condition has not been fully 
appreciated. The results of such an operation are often striking and im- 
mediate, and relief may be given from suffering which has existed for years. 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 233 

A short time ago the author operated on a patient who was suffering 
from repeated attacks of acute abdominal pain attended with symptoms 
of collapse, so much so that the question of perforation was considered, 
more especially as there was a history of previous dysentery. Laparot- 
omy was performed, and strong adhesions binding a portion of the 
small intestines to the lateral aspect of the abdominal wall were discov- 
ered and divided. The whole of the symptoms disappeared. The 
agony had been so intense that the patient dreaded taking food, and 
in consequence was very much emaciated. Recovery was complete. 

No directions suitable for every case can be given. The adhesions 
must be completely divided in order to insure perfect freedom of move- 
ment of the viscera, and, where possible, large raw areas must be cov- 
ered with healthy peritoneum or omentum. If it is correct that silk 
ligatures become permanent foreign bodies, and, therefore, liable to 
cause adhesions, preference must be given to catgut, w T hich is easily 
absorbed. 

Method of Preventing Postoperative Adhesions of Intestines. — 
Charles Cargile, of Bentonville, Ark., has made use of serous mem- 
brane for the purpose of preventing intestinal or abdominal adhesions 
following laparotomy. After a somewhat extended experience the 
Cargile membrane, as it is called, received the indorsements of Robert 
T. Morris, of New York, and John B. Deaver, of Philadelphia. At 
the suggestion of these operators this membrane has been prepared and 
made accessible to the profession through Johnson & Johnson. It is 
put up under the name of "Cargile Membrane," packed in strips 
about 4 by 6 inches, each piece sterilized and inclosed in a double envelope. 
The membrane is very soft, smooth, pliable, and transparent, producing 
no irritation, and adapts itself closely to the surfaces applied to. It is 
intended to act as a protective dressing to the denuded surfaces. It is 
nonirritating and is absorbed in from tw r o to three weeks. More recently 
the late A. B. Craig, of Philadelphia, carried out a series of experiments 
on dogs, using Cargile membrane in an attempt to prevent peritoneal 
adhesions. After careful study and the reopening of abdomens at 
various intervals, he is of opinion that the membrane, for this purpose, is 
practically valueless. 

The author has used in operating for umbilical hernia, where intestinal 
adhesions were most pronounced, a thin layer of carefully sterilized 
goldbeater's skin, w r hich answers the purpose most admirably. 

Operations on the Gastrointestinal Canal.— Whenever the ali- 



234 POSTOPERATIVE TREATMENT. 

mentary canal is opened, septic influences have to be combated, for 
the gastrointestinal contents, under normal conditions, harbor a far 
greater number and variety of bacteria than does the skin. Our first 
care must, therefore, be to endeavor to limit the risk of infection to as 
small an area as possible. The means by which we seek to avoid these 
contingencies are various, and cannot be the same for even' case. The 
method of preventing a spread of infection by means of compresses 
has been considered under the general remarks on laparotomy. But 
the protection of the immediate neighborhood from contamination de- 
pends chiefly upon whether the organ which has been opened can be 
entirely closed, as, for example, in Billroth's second method of pylorec- 
tomy, and in Kocher's method of performing resection of the pylorus, 
in which the stomach is completely closed after the removal of the neo- 
plasm; or whether the opening which has been made has to be joined 
to some other part of the gut in order to form an anastomosis, as in 
gastroenterostomy and the various enteroanastomoses. 

In all cases, and without exception in those in which the mucous 
membrane of the gut has been exposed, a thorough cleansing of the 
surrounding parts must be effected after the suture including all the 
layers has been introduced, and before the serous suture is applied, 
and if necessary, soiled swabs used in shutting off the field of operation 
must be replaced by fresh ones. The certainty of closure of gut or 
stomach always depends on the union of the peritoneum of both ends 
of the gut, but exact apposition of the mucous and muscular coats is 
worthy of more attention than has for some time been paid to it. If 
these layers are properly united, function is more quickly restored, and 
what is far more important, necrosis of the margin of the wound toward 
the lumen of the gut is avoided. Such necrosis rarely, but nevertheless 
occasionally, gives rise to phlegmonous infiltration of stomach wall: 
while more frequently it leads to formation of small foci of infection and 
metastatic inflammation, pneumonia, etc. 

AFTER-TREATMENT OF ABDOMINAL SECTION. 

Method of Sir Frederick Treves. — General Measures. — The 
patient must he absolutely upon the back, and the knees may be kept a 
little flexed by placing a pillow beneath them. A large cradle is placed 
over the trunk. It protects the abdomen from the pressure of the bed- 
clothes, and helps to ventilate the bed. The patient's body is covered 



LAPAROTOMY AND OPERATIONS UPON Till'. ABDOMEN. 235 

by a blanket, which is placed beneath the cradle and in direct contact 
with the trunk. The rest of the bed-clothes are in two sets, so folded 
as to meet transversely in the center of the bed. They are placed over 
or outside the cradle, overlapping at its summit. This arrangement 
permits of the wound being inspected and dressed and enemas, etc., 
given without disturbing the bed-clothes that cover either the upper part 
of the body or the lower limbs. 

The bed should be well warmed with hot bottles before the patient 
is placed in it, and hot bottles may be kept in contact with the feet and 
thorax for some time after the operation. The patient's movements 
should be restrained while consciousness is returning, and the nurse 
may support the wound with the hands during the first attack of vomit- 
ing. The less the patient is interfered with during the first twenty-four 
hours after the operation, the better. Morphin should be avoided 
whenever it is possible, and should never be given as a matter of routine. 
One-sixth of a grain is sufficient at a time. One injection only will 
probably be found to be sufficient. 

The less taken by the mouth during the first twenty-four hours, 
the better. Nothing whatever need be given by the mouth for the first 
nine hours. The patient is then allowed hot water or hot weak tea 
in doses of half an ounce even- half-hour or so. Ice is to be absolutely 
condemned. The reckless and immoderate sucking and bolting of 
lumps of ice, which are encouraged by the nurse who believes a patient 
is doing badly who is not constantly swallowing something, is most perni- 
cious. The stomach becomes filled with cold fluid, and a sense of great 
faintness and discomfort persists until the melted ice is ejected by vomit- 
ing. If really distressing thirst is experienced during the first twenty- 
four hours, it is best relieved by an enema of warm water. Xo other 
form of rectal injection should be allowed. During the second day the 
patient may take hot tea or barley-water in small quantities, provided 
such nourishment does not cause vomiting. 

A catheter should be passed when required. It will not be needed 
during the first twenty-four hours, and the sooner the patient can dis- 
continue its use, the better. The practice of passing a catheter by 
routine once in so many hours is most decidedly to be condemned. 
As a rule, very little urine enters the bladder during the first twenty- 
four hours after operation. Nutrient enemas are not needed except 
in very unusual cases attended with persistent vomiting. In a case that 
is doing well the diet from the third to the fourth day may consist of 



236 POSTOPERATIVE TREATMENT. 

tea and toast, peptonized milk, malted foods, etc. Meat extracts and 
meat jellies of all kinds are to be avoided. Milk is not usually well 
borne, and leads to the formation of scybala, while the indiscreet per- 
severance in a slop diet often causes nausea and flatulence. What food 
is given should be given often and in small quantities. A little fish 
may be given on the fourth day, and meat on the seventh. Through- 
out the progress of an abdominal case patent foods are as much to be 
avoided as patent medicines. 

The bowels may possibly act spontaneously. As a rule, however, 
they do not. In such circumstances an aperient followed by an enema 
should be administered on the third or fourth day. The aperient selected 
should be that which the patient is accustomed to take. Castor oil 
is much to be commended. The enema is most important for the pur- 
pose of clearing out the lower bowel. It may be repeated if there be any 
evidence that the rectum is not well emptied. The injection need not be 
copious; and in cases in which extensive pelvic adhesions have been 
dealt with, even small enemas often cause distress. 

Flatulence or distention of the belly is frequently complained of 
at an early period after the operation. It may to some extent be re- 
lieved by the use of the "rectum tube." This consists in the vaginal 
pipe of an ordinary Higginson's syringe or a large soft-rubber catheter. 
The tube is passed about two or three inches into the rectum, and may 
be left there for ten or fifteen minutes, or so long as it appears to afford 
the patient relief. A small soap-dish must be placed under the free 
end of the tube, to receive any fecal matter that may escape. In these 
cases of flatulent distention minute doses of a carminative, notably 
of one of the aromatic oils, often have a very excellent effect, and the 
same may be said in a lesser degree of sal volatile and spirits of chloro- 
form. A hypodermatic injection of strychnin (g- 1 ^- grain) is sometimes 
useful in overcoming intestinal distention. But probably the simplest 
and most efficacious measure is to turn the patient on the side for a 
time. This can often be done with safety, and affords relief to the back- 
ache so frequently complained of. 

Now and then it will be found that about or before the seventh day 
after the operation — often about the fourth or fifth — the abdomen is 
distended, the tongue is coated and foul, the belly is tender, and com- 
plaint is made of the tightness of the binder, while there may be a little 
vomiting or nausea. The temperature remains normal, the respiration 
unaffected, the complexion unaltered, and the pulse and general condi- 






LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 237 

tion good. The symptoms in such a case may depend upon the fact 
that the bowels had not been well evacuated before the operation, or 
the intestine may have been partially paralyzed by too much opium, 
or the diet since the operation may have been such as to lead to tympan- 
itic distention. The lavish use of meat extracts or concentrated meat 
preparations is very likely to be followed by great distention due to decom- 
position. The patient \vho # presents these symptoms is often greatly 
relieved by a saline or other aperient. The bowel is well cleared out, 
and the sickness, pain, and distention vanish. It is possible that cases 
of this character, relieved in the manner indicated, may have been 
described as examples of acute peritonitis treated by saline aperients. 

The graver complications after abdominal section — among which 
may be mentioned internal hemorrhage, peritonitis, septicemia, intes- 
tinal obstruction, fecal fistula, thrombosis, parotitis, and pulmonary 
embolism — must be treated according to the measures advised in the 
treatises on surgery. 

After-treatment of the Wound. — The dressing may be removed 
on the fourth day. The wound should be kept dry. It needs no wash- 
ing, nor to be touched with anything moist. The dried iodoform pow- 
der is picked off with sterilized forceps, and fresh iodoform is applied 
under a new dry dressing. The binder and thigh pieces are once more 
adjusted. The sutures should, as a rule, be left in for ten, twelve, or 
even fifteen days. In other words, a firm scar should have time to 
form before they are removed. The retention of the stitches will 
enable the operator to dispense with the subsequent use of strapping. 

Throughout the whole period of convalescence the binder should be 
retained, and be always carefully applied. In cases in which the wound 
has become infected and fails to heal, or in which is has burst 
open after the removal of the sutures by reason of violent expiratory 
movements on the part of the patient, or in which the incision has been 
deliberately opened up by the surgeon, the margins should be kept 
well adjusted by means of strapping, which in such cases will require 
to be reapplied once, or possibly twice, in the twenty-four hours. 

For the first fortnight after the operation the patient should lie upon 
the back and be kept as still as possible. At the end of this time he or 
she may be allowed to be a little raised in bed, or to lie upon one side 
while the back is well supported with pillows. Between the third and 
the fourth week the patient may be allowed to get up. Such are the 
times which may be observed in an ordinary case of average severity. 



238 POSTOPERATIVE TREATMENT. 

In a large proportion of instances it is well that the patient should remain 
in bed one month, whereas in the simplest exploratory operations the 
patient may be allowed up on the eighteenth day, or even before. Some 
surgeons will allow a woman convalescent from ovariotomy to leave 
the hospital on the eighteenth day. It is well, probably, to err in the 
direction of encouraging a longer period of rest after these operations. 
Some complications, notably that of phlegmasia, appear to be encouraged 
by too early movement. 

In a few cases before the patient leaves the surgeon's care an ab- 
dominal belt should be ordered. This should be largely composed of 
elastic, and may be worn from three to six months. After the simplest 
procedures a flannel binder is all that is necessary; but in cases of pen- 
dulous abdomen, and in instances in which the healing of the wound 
has been imperfect or interrupted, or a very large tumor has been 
removed, a well-made and very carefully fitted belt is required. The 
primary object of a belt in these cases is to assist the cicatrix in resisting 
the weight of the viscera and the passive pressure from within. It 
must be remembered that the abdominal wall is made up of muscular 
and aponeurotic tissues. It is required that these tissues should not 
be weakened. Like tissues elsewhere, they atrophy from disuse and 
are rendered strong by exercise. The very elaborate, rigid, and heavy 
belts which are sometimes worn after abdominal section, especially 
after ovariotomy, may possibly do harm by taking upon themselves 
too much of the function of the muscles and aponeuroses. 

APPENDICECTOMY. 

General Principles. — Aseptic operations or operations performed 
after all acute symptoms of inflammation have subsided require the 
same general principles of after-treatment as those following ordinary 
laparotomies, but if the operation has been performed when inflam- 
mation or suppuration is present, the wound must be treated after the 
open method. According to Kocher, acute appendicitis is almost 
always an exudative periappendicitis, generally the result of perfora- 
tion, and should be treated accordingly. 

In all operations for the removal of the appendix when inflamma- 
tion is present, Bernays places a strip of 5 percent iodoform gauze 
around the stump of the appendix and on every piece of gut on which 
there is a deposit of fibrin or any discoloration or suppuration. Thor- 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 239 

ough drainage is secured by means of these strips, the important point 
being to connect each area of injection with the external wound by the 
shortest possible route. After three or four days the gauze drainage 
strips are gradually withdrawn, and if upon final removal there is much 
evidence of suppuration, repacking may be necessary. 

If the case is one of purulent perityphlitis or periappendicitis, the 
treatment is obvious. The abscess must be opened, drained and kept 
thoroughly evacuated. When the abscess is well defined and walled off 
from the peritoneal cavity, the utmost caution is necessary to prevent 
disturbance or destruction of the adhesions. Frequently in spite of 
gauze drainage these large abscesses heal slowly, in which case the 
abscess cavity should be repacked daily with strips of iodoform gauze 
saturated with sterile cosmolin or balsam of Peru ; the former has proved 
very beneficial in our hands. If the abscess is complicated by fecal 
fistula, this method of repacking daily will ordinarily suffice to bring 
about a cure in three or four weeks. If, however, the fecal fistula is 
large and the patient is declining in health, to shorten the period of 
convalescence, and render recovery more probable, after gentle but 
thorough irrigation with normal salt solution of the abscess-cavity a 
radical operation for the removal of the appendix should be performed 
exactly as during the acute stage. A fresh incision is made quite apart 
from the one communicating with the abscess-cavity and as far removed 
from it as possible, i.e., to the border of the rectus muscle. The adhe- 
sions are carefully broken down, the appendix isolated and brought 
up into the wound, together with the cecum if necessary, and the appen- 
dix amputated by the usual method. The small intestine and cecum, 
which may be covered with lymph, must be carefully examined for 
perforations. The fresh abdominal wound may now be closed and 
sealed, but the wound leading to the abscess-cavity should be treated 
after the open method, i.e., packed with strips of iodoform gauze passed 
well down to the bottom of the cavity. Glass or rubber tubes, as a 
rule, should not be used. By means of this procedure we have seen 
large fecal fistulas and abscesses heal with comparative rapidity. 

Multiple abscesses following appendicectomy are of frequent 
occurrence. They usually appear within a week or ten days follow- 
ing the operation, and are known to be present by a sudden rise of 
temperature, with pain in the region of the wound. They may appear 
subcutaneously as a hard lump or swelling, or may form in the deeper 
parts of the wound or cavity. Careful exploration with a probe will 



- 



POSTOPERATIVE TREATMENT. 



usually reveal the scat of the pus, which must be given free exit. 
Thorough exploration under anesthesia may be necessa: 

It frequently happens that a counteropening is necessary to secure 
better drainage, especially when irrigation is desirable. Fig. 73 illus- 
trates this condition, although, especially in postcecal abscess. 
counteropening through the posterior or lumbar region is more desirable. 

Immediately following all severe septic operations a tight abdominal 
bandage (preferably broad adhesive strips) should be applied, to pre- 
vent distention; and lavage of the stomach should be given before the 
patient is removed from the operating table. So soon as possible after 




FlG. -: — SOUNTEROPENING TO Si 



-_ 7 ..-■ ~.:-z. 



anesthesia the patient should be allowed plenty of water to drink, but 
no food of any character should be given by the stomach for from three 
to four days. If all food is withheld, morphin or opium may safely 
be given, and if peritonitis is present, we know of no remedy more 
potent in its quieting influence upon the nervous system or in preserving 
the strength of the patient. It likev: sts nature by keeping the 

bowels quiet, thus favoring adhesions and resolution. The early 
and indiscrim in ate use of calomel or other purgatives, so commonly 
:ribed after all laparotomies, is mentioned only to be condemned. 
As a rule, no purgatives should be administered until the bowels manifest 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 241 

a disposition to move by the rumbling of gas or other symptoms. If 
meteorism is present, it may call for the introduction of the rectal tube, 
or high enemas of glycerin may be used as described on page 45. 

Ochsner's method of treating the more severe types of appendicitis 
prior to operative measures has met such general approval that I feel 
confident if the same common-sense measures were applied to the 
after-cure of severe septic cases the mortality would be greatly lessened ; 
viz., the prohibition of every kind of food and cathartics by the mouth, 
and the employment of gastric lavage as indicated by the presence of 
nausea, vomiting, or meteorism. 

After-treatment (Ochsner.) — For the first three or four days the 
patient should be sustained entirely by rectal feeding, nutrient enemas 
being given every four hours (concentrated predigested food in quantity 
no more than four ounces); if the patient is normal at the end of this 
time, a moderate amount of liquid nourishment may be given by the 
mouth at regular intervals, but if the patient is not normal at the end 
of this time, the rectal enemas should be continued. In case of pain 
or restlessness morphin can be safely given, preferably by hypodermatic 
injections, so long as no food is given by the mouth. 

Postoperative Treatment of Appendicectomy as Advocated by 
Brewer. — In interval cases and in early acute conditions when the 
abdomen is tightly closed little postoperative interference is necessary 
if the case progresses favorably. Morphin in small doses may be required 
during the first twenty-four hours to relieve pain. The bowels should 
be moved on the third or fourth day. For this, small doses of calomel 
should be administered, followed by a saline draft, and enemas if 
necessary. 

If much morphin has been used, there may be considerable difficulty 
in bringing about a movement, on account of the tendency to nausea 
which prevents the free use of salts. In these cases the frequent use 
of high enemas will generally be successful if there is not peritonitis. 
If the pulse and temperature are normal, the dressing need not be changed 
for six or eight days. Obstinate vomiting after operation can generally 
be relieved by lavage, followed by absolute rest of the stomach, not 
even water being allowed. The practice of giving medicines to relieve 
postoperative vomiting is to be condemned, as they nearly always serve 
to aggravate the condition. Continued pain and vomiting after operation 
point to peritoneal irritation; and if the pulse and temperature are 
elevated and the abdominal tenderness, rigidity, and distention are 
16 



242 POSTOPERATIVE TREATMENT. 

increased, there is strong reason to suspect a spreading peritonitis. 
In these cases the wound should be reopened under anesthesia and the 
peritonitis treated as indicated above. In acute cases in which drainage 
is employed, the wound should be inspected frequently and the outside 
dressings changed as often as they become saturated with the wound 
secretions. If the temperature and pulse remain elevated, and if ten- 
derness and rigidity are present, the drains should be removed and any 
retained pus evacuated. Digital exploration of the wound with the 
gloved hand will often enable the surgeon to recognize a collection of 
pus by the induration, which may not be apparent on superficial abdom- 
inal palpation. Such deep-seated collections of pus are often drained 
best by rubber tubes until the acuteness of the symptoms has subsided. 
As soon as the sinuses are reasonably clear and granulations appear, 
further packing is unnecessary and only delays recovery. 

In the treatment of a generalized peritonitis the chief indication is 
to combat sepsis. After the primary focus of infection has been removed 
and provision made for drainage, ehmination should be favored by the 
action of the bowels, the kidneys, and the skin. Calomel should be 
administered as soon as the postanesthetic vomiting has ceased, followed 
by salines and high enemas. If the medicines are rejected by the 
stomach, it should be washed out and salts introduced through the 
stomach-tube. Enemas of turpentine, glycerin, and a saturated solu- 
tion of epsom salt should be given every hour, followed by rectal irri- 
gation with hot salt solution. Intravenous infusions are of the greatest 
value in stimulating the secretion of urine and inducing active diaphore- 
sis. Cardiac stimulants, as strychnin, digitalis, caffein, and alcohol, 
should be freely given. Sponge-baths and hot packs will often relieve 
t,he intense restlessness and high temperature. The practice of aban- 
doning to their fate patients who develop generalized peritonitis cannot 
be too strongly condemned. While the great majority of such patients 
eventually succumb in spite of all treatment, desperate cases are saved 
occasionally by energetic and persistent treatment. The author has 
recently seen such a patient recover after days of continuous vomiting 
of intestinal matter, enormous distention of the abdomen, a tempera- 
ture of 108.5 F., and a pulse that could not be countedt In this case 
every available cutaneous vein in the body had been used for saline 
infusion. Localized abscesses in various parts of the abdominal 
cavity are not infrequent during convalescence from a diffuse peritonitis. 
Their presence is indicated by an acute rise in temperature and pulse, 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 243 

a high leukocytosis, prostration, and the occurrence of sweats. The 
tenderness may be slight even in large collections of pus, and should 
be sought for carefully by abdominal palpation and vaginal or rectal 
examination. The symptoms will promptly subside as soon as the 
focus is located and adequately drained. 

Fecal fistula not infrequently follows appendicitis, especially if 
the appendix and cecum are greatly infiltrated and surrounded by an 
abscess. In these cases removal of the appendix mav result in injury 
to the wall of the gut, and a ligature placed around the stump may 
cut through before it is tightened sufficiently to occlude the lumen of 
the tube. Under these conditions a fistula may often be prevented by 
drawing a piece of omentum over the stump and suturing it to the cecal 
wall. The treatment of fecal fistula consists in cleanliness and fre- 
quent dressings. Drainage should be removed as soon as the sinus is 
sufficiently organized to remain patent, and the opening allowed to 
heal by granulation. The great majority of these cases heal sponta- 
neously. 

Ventral hernia frequently follows operations for acute appendicitis, 
especially if the wound is allowed to remain open for drainage. The 
treatment is the same as for other varieties of postoperative ventral 
hernia. 

THE AFTER-TREATMENT OF OVARIOTOMY ACCORDING 
TO HOWARD A. KELLY. 

Comparatively full details of treatment following most abdominal 
operations have already been described under the head of laparotomy, 
but certain minor details, so necessary to the comfort and welfare of 
the patient, have been so clearly and forcibly described by Howard 
A. Kelly that I feel warranted in placing his ideas in full before the 
reader. 

"Before leaving the operating table the patient is given a high rectal 
injection of one pint of normal salt solution at a temperature of 108 
F. She is then carried to her room and placed in a warm, comfortable 
bed. The room should be darkened and the patient left in exclusive 
charge of the nurse, who should under no circumstances leave her alone 
for a minute until the effects of the anesthetic have worn off. Restraint 
must be exercised while under the effects of the anesthesia and pass- 
ing off only to the extent of preventing the patient from falling out of 
bed or tossing to and fro. 



244 POSTOPERATIVE TREATMENT. 

"Position in Bed. — It is not necessary for the patient to remain 
persistently upon the back; on the contrary, she may be carefully turned 
from one side to the other if the change makes her more comfortable. 

"Use of Morphin. — If, after the effects of the anesthetic have passed 
away the patient is very restless, or if she has severe pain, which fre- 
quently follows oophorectomy, morphin, J to J grain, may be given 
hypodermatically, and the dose repeated if sleep during the first night 
cannot be secured without it. Milder sedatives are useless, but mor- 
phin should not be continued longer than twenty-four to thirty-six 
hours. If the patient is hysterical, codein may act better than mor- 
phin. Violent movements should be controlled as far as possible by 
moral suasion, with efforts at gentle restraint. Under no circum- 
stances should a woman semiconscious and writhing in pain be placed 
in a canvas strait-jacket and pinned down to the bed by force. They 
are far more liable to injury in this way than if left uncontrolled. 

"Nausea. — The nausea from the anesthetic is variable, being most 
pronounced after long operations; it usually ceases in from twenty- 
four to forty- eight hours, although it may last three or four days, or 
even a week. Little or no nourishment should be given at first while 
the vomiting is active. If the patient is weak and the nausea persists, 
nutrient rectal enemas of a small cupful of peptonized milk and the 
yolks of two eggs, with salt, may be given every six or eight hours. Nau- 
sea will often be relieved by teaspoonfuls of very hot water, or a drop or 
two of tincture of capsicum in water, or a quarter of a drop of creasote 
in a teaspoonful of lime-water. A mustard plaster over the pit of the 
stomach often helps. (For treatment of severe forms of vomiting by 
washing out of the stomach see page 84.) 

"Toilet. — The personal care of the patient devolving upon the nurse 
is so important that I add a few directions about cleanliness and toilet. 
As soon as consciousness returns the hands and face are bathed in cool 
water and the mouth cleansed with a gauze sponge dipped in ice- water. 
If there is a tendency to choke up with mucus, the fauces must be wiped 
out with a clean napkin used far back in the throat. When the patient 
is strong enough, a gargle of warm water relieves the thirst and the 
unpleasant taste of ether in the mouth. The head must be kept low, 
without a pillow at first, to assist breathing and to lessen the nausea. 
A hair pillow under the flexed knees gives a more comfortable position. 

"Bathing. — The morning after the operation the patient may be 
given an alcohol bath — one part alcohol and three parts water — at a 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 245 

temperature of 120 F. Beginning with face and arms, carefully placing 
towels under the parts so as not to wet the bed, and exposing small 
portions at a time, the whole body may be washed with a soft gauze 
cloth. The alcohol bath should be given during the first forty-eight 
hours, after which the regular daily bath of warm water and soap may 
be resumed. 

"Food. — The first food given should be a teaspoonful of milk or 
hot weak tea at half-hour intervals, increasing the quantity as the 
stomach becomes tolerant ; lime-water may be added to the milk. Strong 
coffee is also occasionally valuable as a stimulant. Egg-albumen is a 
tasteless and most nutritious food. It is prepared by beating up the 
whites of four eggs into a liquid froth, and allowing it to stand in a cool 
place for an hour or more, when 50 c.c. (about 2 ounces) of liquid 
albumen may be drained off, leaving the frothy part behind. Another 
way of preparing albumen is to pour the white of one egg over half 
a glass of finely crushed ice, stirring gently and adding a little sugar 
and lemon. Egg-albumen should be made fresh every six to twelve 
hours, according to the time of year. It is best given a teaspoonful 
or two at a time, mixed in two or three tablespoonfuls of cold water, 
with a little sugar, and flavored with five or ten drops of lemon-juice; 
if preferred, a teaspoonful of sherry wine may be added. 

"Additional articles of liquid diet are chicken broth, beef -tea, and 
the various gruels. Hot oyster-soup, with the oysters taken out, is a 
valuable and appetizing addition to the diet-list when other liquids 
have become tiresome. Wine whey and clam-juice are occasionally 
useful. From 120 to 250 c.c. (4 to 8 ounces) of nourishment will be 
taken in this way in the second twenty-four hours, increased to 300 
to 400 c.c. (10 to 13 ounces) in the third. From the third or fourth 
to the seventh day, if all is going well, soft diet may be given. This 
consists of soft-boiled eggs, milk-toast, bread, soups, custards, and 
jellies, with milk-punch or egg-nog. After the first week stronger diet 
may be gradually resumed. 

"As the widest divergence of opinion may and does exist as to what 
a liquid or a soft diet is, I add hereto a diet-list prepared by an ex- 
perienced nurse. 

" DIET-LISTS. 

11 Liquid Food: 

"Milk. — Plain, peptonized, sterilized, malted; with albumen, milk- 
punch, egg-nog, koumiss. 



246 POSTOPERATIVE TREATMENT. 

"Wines. — Grape-juice (unfermented), cocoa cordial, wine whey, 
mulled wine, sherry whip. 

"Broths. — Beef-tea, beef broth, boiled beef essence, chicken broth, 
oyster broth, clam broth, somatose. 

"Soups. — Mock bisque, tomato, cream of rice, cream of asparagus, 
cream of pea, consomme, bouillon. 
"Soft Foods: 

"Eggs. — Poached, shirred, soft-boiled. 

"Jellies. — Wine, orange, or coffee jelly. 

"Creams. — Apple float; whipped, ' orange, or Spanish cream; cream 
of tapioca, cream of rice; baked custard in cups, boiled custard with 
float, tapioca with baked apples, arrow-root blanc-mange, orange 
sherbet, lemon sherbet, junket (plain or made with wine), panada. 

" SPECIAL DIETS. 

" Oysters and Sweetbreads. — Creamed oysters, boiled oysters, . oysters 
on the half-shell; creamed sweetbreads, broiled sweetbreads. 

"Eggs. — Poached, shirred, soft-boiled. 

"Beef. — Scraped beef sandwiches. 

"Birds. — Partridges (boiled or roasted), broiled squab, chicken 
stewed with rice. 

"Porridge. — Wheat flakes, oatmeal (strained). 

" Thirst. — The thirst for the first twelve hours after abdominal 
section is sometimes overpowering, and the patient in her desire to allay 
it scarcely knows what she is doing. One of my patients, a desperate 
ovariotomy case, reached down to her feet and pulled up the hot- water 
bag, from which she drank at least a quart of warm water. Another, 
a colored girl, with general suppurative peritonitis, and with a drain- 
age-tube in the abdomen, got out of bed, walked into the hall, and 
drank a large quantity of water from the spigot of the water-cooler; 
neither of them was apparently hurt by her experience. (For the treat- 
ment of this important symptom see page 95.) 

" Irritability of the Bladder and Decrease in Urinary Excretion. 
— The temporary partial suppression of urine for the first four or five 
days after an abdominal section is frequently so marked as to give rise 
to a fear of the possibility of some grave renal disturbance. 

"In a paper by W. W. Russel ('Johns Hopkins Hospital Reports,' 
1894), after a careful review of the urinary charts of many cases, the 
conclusion was reached that the frequency of vesical irritability in post- 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 247 

operative cases was due lo the retention of small quantities of highly 
concentrated urine in the bladder. This theory is unquestionably 
correct, for a noteworthy increase in the amount of urine excreted after 
saline enemas has been followed by a marked decrease in the frequency 
of catheterization, and in vesical irritability, and consequently post- 
operative cystitis or vesical irritability now rarely occurs. 

"A comparison by Clark of a series of ioo cases in which saline 
enemas were used, with a series of ioo cases without them, shows these 
interesting points: 'The natural result of almost doubling the watery 
constituent of the urine is to decrease the specific gravity. The specific 
gravity of cases in which enemas are not given ranges between 1025 
and 1030, while those with it show a reduction to an average of 102 1.' 

"There appears to be a further explanation for the greater excretion 
of urine in the cases which have the saline enemas than that it is merely 
due to an increase in the amount of water taken into the system. The 
nausea and vomiting following anesthesia usually disappear by the end 
of the first twenty-four hours, after which the imbibition of water has 
not been restricted in either series. 

" Notwithstanding the fact that in both series of cases about the 
same quantity of water is taken by the mouth, the excretion in one 
remains very low for three days, at no time being above 505 c.c, while 
the other shows not less than 600 c.c, or over 100 cubic centimeters 
more urine passed daily by the patients who have had the enemas. 
From this observation it w r ould appear that the persistent renal tor- 
pidity is due to the irritant or toxic effects of the greatly concentrated 
urine, and by supplying the body with a liter of salt solution this partial 
suppression is to a great extent prevented, and the kidney at once 
resumes its normal function as soon as the patient begins to take water. 

"Catheter. — The catheter should only be used to draw the urine, 
if the patient is unable to pass it naturally after six or eight hours, and 
then the utmost care must be taken to pass a clean catheter, through a 
clean urethral orifice, under inspection. If the catheter has to be used 
at all, its use must be discontinued as soon as possible. If vesical 
irritability is persistent, it will improve upon taking spirits of nitrous 
ether, 20 to 30 drops, every two hours, or 5 drops of copaiba in cap- 
sules three times a day. Balsch ('Munchener medicinische Wochen- 
schrift') states that repeated catheterization may be avoided and the 
bladder made to assume its normal contractility by injecting into the 
distended bladder 20 cubic centimeters of a sterilized 2 percent solution 



248 POSTOPERATIVE TREATMENT. 

of boric acid in glycerin. In the majority of cases this procedure is 
followed by an evacuation of the bladder without tenesmus in from 
five to ten minutes, and the patient usually is thereafter able to urinate 
spontaneously. 

"Bowels. — I have often noticed that surgeons grow too anxious 
and work too hard to get the bowels moved for the first time. If the 
patient is doing well in other ways, it need cause no worry should the 
bowels be sluggish and not respond until as late as the fifth or sixth 
day. Often after two or three days of active efforts if the patient is 
left quite alone they move spontaneously in six or eight hours. 

"As a routine line of treatment I give on the evening of the second 
day something which will move the bowels on the following morning. 
Calomel will be found to be the most efficacious, and is, as a rule, best 
borne by the patient. It can be given in one dose of 2 or 3 grains, 
or J to \ of a grain may be given every hour until the same amount is 
reached, followed in the morning by 6 to 8 ounces of a solution of mag- 
nesium citrate. About two hours later an enema of 100 c.c. of olive 
oil with 30 c.c. of glycerin should be injected as high as possible into 
the rectum. If this is not effective, four to six hours may be allowed 
to elapse before another attempt is made with an injection, consisting 
of a pint of water at a temperature of ioo° F. and soapsuds. 

"A satisfactory saline enema much used by C. P. Noble is the follow- 
ing concentrated solution of the sulfate of magnesia: 

Magnesium sulfate, o ij 

Oil of turpentine o ss 

Glycerin, 5 j 

Water enough to make oiv 

Mix and inject in bowel. 

"It is not advisable to use more than three enemas during the third 
day; it is better to assist the calomel by castor oil or magnesium sulfate 
in half-ounce doses, or by a pill of aloin, strychnin, and belladonna. 
When the bowels are once opened, they should be kept open by a move- 
ment at least every other day. 

" Tympanites, which often occasions much distress, is usually speedily 
relieved by the free evacuation of the bowels. Drop doses of tincture 
of capsicum, or a few drops of tincture of nux vomica in a teaspoon- 
ful of hot pepper tea, are valuable adjuvants. A rectal enema of three 
ounces of milk of asafetida will also often relieve it. 

" Temperature. — The temperature must always be carefully watched. 



LAPAROTOMY AND OPERATIONS II'OX THE ABDOMEN. 249 

On the second or third day it is commonly elevated to ioo° F., or even 
101 F., but it usually drops with the first free movement of the bowels. 
This slight rise in temperature appears to be due to the absorption 
of a fibrin ferment, and it may in exceptional cases be prolonged for 
several days beyond the usual period. A persistent temperature, 
however, above ioo° is in most cases due to infection either of the wound 
or in the peritoneum. A sudden rise in temperature, sometimes attended 
with a chill, toward the end of the first week, is often the first indication 
of suppuration in the abdominal wall. The wound should be inspected 
immediately for any hard, red, tender areas on one side or the other, 
the stitch or stitches at that point removed, and the lips of the incision 
slightly separated, to favor the discharge of pus. When the pus has 
escaped, the temperature falls at once. 

"Pulse. — The pulse is likely to remain quickened 20 or 30 beats 
or more for three or four days after any severe operation. If the general 
condition is good, and the pulse full and compressible, this need cause 
no anxiety. The normal course is a steadily falling pulse after operation, 
falling less rapidly if there is much pain. A falling pulse is a good 
sign; a rising pulse always calls for investigation. In general, a pulse 
of from 120 to 130 beats needs watching; a pulse of 140 beats needs 
closer watching; a pulse of 150 beats needs anxious watching; a patient 
with a pulse of 160 beats does not, as a rule, recover unless it begins 
to fall within six to twelve hours after the operation. Neither the 
temperature nor the pulse, however, should be studied alone, but always 
in association. If the pulse is high — from 120 to 140 beats — combined 
with a high temperature after the first day, when the bowels have been 
freely moved, infection has probably taken place. The most satisfactory 
sign of progress is a free evacuation of the bowels, with a pulse and 
temperature dropping together. 

" Facial Expression. — Facial expression is a sign scarcely less signifi- 
cant than the temperature and pulse, and, taken together with these 
forms, is a good index of the general condition. A bright natural 
expression is to be looked for during the normal convalescence; a 
flushed, dusky, anxious, haggard, or a lack-luster expression is indica- 
tive of complications. 

11 Dressing of the Wound. — Unless some special cause arises, the 
wound need not be dressed until the tenth day, when fresh gauze and 
cotton dressings should be put on with the dressing forceps. The 
bandage may be changed daily, and the back well rubbed with a solution 



250 POSTOPERATIVE TREATMENT. 

of alcohol and water, half and half. Boric acid and bismuth powder 
are also good to rub into the back. This rubbing is the best treatment 
for the severe pain so constantly felt in the back. 

" Sutures. — The use of buried catgut suture may relieve the patient, 
if explained, of considerable anxiety, for often the removal of sutures 
is looked forward to with great dread. The abdominal dressings 
need not be disturbed until the tenth day except in case of wound infec- 
tion. They should be carefully lifted off and replaced by several layers 
of fresh sterilized gauze. If they have become adherent to the incision, 
a little sterilized water poured on will rapidly loosen them. The skin 
about the incision should not be cleansed until about the fourteenth 
day. Pledgets of cotton wet with dilute alcohol are best for this purpose. 
The catgut sterilized by the cumol method is usually absorbed by the 
eighth to the tenth day. Silkworm-gut sutures are removed on the 
tenth to the fourteenth day. First expose the loop by pulling up the 
suture a little with forceps, then cut it close to the skin and draw it out 
toward the side on which it is cut, to avoid pulling the edges of the 
wound apart. Adhesive straps across the wound after removing the 
sutures are sometimes necessary. If the bandage is kept well in place, 
and put on snugly every time the wound- surfaces will naturally remain 
in close approximation. 

" Convalescence. — After ten or twelve days usually the patient may 
be propped up with pillows or on a bed-rest; and in from seventeen to 
twenty-one days, according to the rapidity with which strength is 
regained, she may spend part of the time in a reclining chair or on a 
sofa. Throughout the convalescence she must avoid straining the 
abdominal muscles. While still abed she must not raise herself to a 
sitting posture or change her position without aid. Later she must 
not stoop or lift heavy weights. During active vomiting the least 
strained position is lying on the side with the body slightly flexed, or on 
the back with the knees drawn up resting on a pillow. At the end of 
the fourth or fifth week she should be able to walk around and perhaps 
go downstairs. All bodily movements should be gentle at first. The 
patient should not sit up long enough at first to grow tired of the new- 
ness of it, and later on she should avoid tiring herself on her feet. It 
is best not to hasten the getting out of bed, as a prolonged absolute 
rest is an important element in securing complete restoration to health. 
Heavy work and exhausting exercise of all kinds must be avoided. 

"The convalescence is by no means at an end when the patient is 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 25 1 

able to return to her home. Disappointment will frequently be avoided 
if she is warned of this beforehand, and kept under observation for a 
year or more while regaining her physical and nervous balance and 
passing the period of any unpleasant sequels, such as flushes, sweatings, 
giddiness, and various other nervous manifestations. Sometimes some 
of the original discomforts persist for months, only disappearing grad- 
ually, so that complete recovery to health does not take place until 
after a year or a year and a half. 

" Fresh air, rest, diet, and tonic treatment, with encouragement, 
are the most important aids in convalescence. Change of air and 
scenes is of the greatest value in bringing about complete restoration 
to health. The golf field is the best form of moderate exercise I know 
of, and will prove an invaluable adjuvant as soon as the patient is able 
to take a little active out-of-door exercise." 

PYOSALPINX, ABSCESS OF OVARY, ETC. 

The after-treatment depends largely upon the extent of the oper- 
ation, adhesions of the intestines, etc. When it is possible to remove 
the pus-tubes without rupture, causing the escape of pus into the pelvis 
or abdominal cavity, careful toilet of the peritoneal cavity is usually 
all that is required, after which the abdominal wound may be closed 
and the after-treatment will be the same as after any septic operation; 
but should an abscess rupture during an operation or should pus escape 
accidentally, the pelvis should be thoroughly cleansed with sponges, 
and then the sides of the incision may be pulled up and as much hot 
salt solution poured in as the pelvis will hold. Kelly recommends that 
the hot salt solution should be stirred about in the pelvis with the hand 
or with a sponge on a holder, and the water then sponged out and more 
poured in. This may be repeated several times until the surgeon is 
satisfied that the pus has been well diluted and removed. No drain- 
age will then be necessary. If, however, there is a distinct focus of 
infection or an injured bowel left behind, a vaginal gauze drainage 
should be inserted behind the cervix. 

Pelvic Abscess. — If the operation discloses a large pelvic abscess 
with a widespread or a general purulent peritonitis, the course pursued 
by the operator must depend upon the condition of the patient. The 
best plan is to make a posterior vaginal counteropening, to irrigate 
rapidly, clearing out all accessible pus with a sponge, paying special 



252 POSTOPERATIVE TREATMENT. 

attention to the pelvic and renal fossas. The abscess walls with the 
ovary or pus-tube should be carefully enucleated. When the patient's 
condition will permit, the entire abdominal cavity should be washed 
out, and the separate coils of intestines drawn up and carefully wiped, 
so that as far as possible every trace of pus is removed. Careful but 
thorough flushing with normal salt solution, repeated several times, 
should be done as rapidly as possible. A liberal gauze drainage should 
then be inserted through the abdominal incision, pushed down into the 
pelvis, and drawn out through the vaginal incision. In this way several 
yards of gauze may be employed and gradually removed by the third 
or fourth day. Some surgeons prefer the insertion of a large glass 
drainage-tube through the lower portion of the abdominal incision, 
which, together with a small gauze drainage via the vagina, is ordinarily 
sufficient, but, in our experience, the more thorough the drainage, the 
better the prospects of recovery. 

The following case, reported by R. C. Turck, of Chicago ("Med- 
ical Standard," May, 1903), is typical of many of the severe cases of this 
character and contains an abundance of interesting and instructive 
features : 

"Miss E., age twenty-eight. Double pyosalpinx, appendicitis, general 
peritonitis. Entered hospital with symptoms of a general peritonitis. Had had 
abortion with subsequent septic infection five weeks previously; condition 
desperate; had been transfused intravenously before taken to the hospital in 
ambulance. Examination showed intense, diffuse abdominal pain, disten- 
tion, tympanites, pulse weak and rapid, temperature 101 F., respiration 28; 
pelvic region extremely tender, apparently a mass of inflamed and adherent 
viscera. Treated for eight days by constant hot fomentations, liquid diet, 
morphin, nutrient enemas, lysol douches, etc., reducing pain, temperature, 
distention, and inflammation. 

" Operation. — Median abdominal incision. Pelvis and abdomen filled 
with flocculent, serosanguineous fluid; pelvic viscera, bowel, and omentum 
formed an agglutinated mass. Broke up adhesions between uterus, ovaries, 
both enlarged tubes and pelvic wall, bladder, rectum, bowel, and omentum. 
Left ovary and tube lying in bottom of pelvis. Amputated together with 
uterine horn. Obliged to cut away large amounts of adherent omentum. 
Right tube also directed downward with vermiform appendix, highly in- 
flamed, closely adherent to it. Removed appendix and tube and part of 
ovary. Great amount of raw surface, with much oozing. Toilet with dry 
sponges. Cut through posterior vaginal wall (Douglas's pouch, and packed 
deep pelvis with iodoform gauze, carrying end out through the vagina. In- 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 253 

serted large Mikulicz drain deeply through abdominal wound, with glass tube 
in center of drain. Gave 1000 c.c. normal salt under breasts on operating 
table. Strychnin hypodermatically. Patient left table in practical collapse. 
"After-treatment. — Strychnin, -5V grain hypodermatically every two hours; 
normal salt solution, temperature 108 F. One pint by the rectum every 
three hours. Drainage during the first twenty-four hours twelve ounces 
from tube; second day, seven ounces; then an average of three ounces for 
six days. Normal salt per rectum not retained after fourth day. Tempera- 
ture never above ioo° F. after forty-eight hours. Removed tube on eighth 
day; also part of gauze below and all of the Mikulicz drain; irrigated and 
repacked; established through-and-through drainage and irrigation (i. e., in 
abdominal wound and out vagina). Temperature normal after seventeenth 
day. Wound gradually healed. Left hospital, walking, on the thirty-fifth 
day. Wounds completely healed, with patient in excellent condition, gaining 
weight and strength, no pain, at end of seventh week." 

Pelvic abscesses after thorough evacuation should be carefully packed 
with iodoform gauze or iodoform gauze dipped in balsam of Peru. 
The patient must be kept absolutely at rest, bowels freely open. Anti- 
septic hot vaginal douches frequently afford relief. If the condition 
of the patient remains good, the gauze packing should not be disturbed 
for three or four days or longer, or until the packing becomes loosened, 
when all the gauze may be removed with a suitable pair of forceps, 
and the cavity cleansed with hydrogen peroxid or boric-acid solution, 
and a fresh iodoform packing applied. This cleansing or dressing is 
renewed daily, preferably by using speculum and dressing forceps 
instead of the fingers. Some surgeons prefer to withdraw the gauze 
drainage slowly, removing three or four inches daily and not washing 
out the sac until the gauze is all removed — by about the tenth day. 
If, how r ever, the pelvic peritoneal cavity is opened, the pus must be 
thoroughly removed, the cavity wiped out and packed, and irrigation, 
if used at all, must be in small quantities and with the utmost care. 
In vaginal drainage great care is necessary to avoid a fecal fistula; 
notwithstanding the greatest precaution, a small opening into the bowel 
may be made, but will usually heal quickly if the cavity is well packed 
with gauze so as to prevent fecal matter entering the abscess sac. When 
this accident happens, the gauze must be removed daily and the pus 
cavity well irrigated, followed by a firm application of fresh gauze. 
When the cellular tissue is more or less honeycombed with multiple 
abscesses, the progress of a case will necessarily be slow and may require 



254 ' POSTOPERATIVE TREATMENT. 

repeated puncture. If the patient does not improve, or if the pain, 
tenderness, and elevation of pulse and temperature indicate further 
extension of infection, or if all the pus-cavities have not been evacuated, 
abdominal incision to secure perfect drainage may become necessary. 

APPENDICULAR ABSCESS, PYOSALPINX, OR SEPTIC 
PERITONITIS. 

Method of Drainage after Operation (Nicholas Senn). — "At 

present there are three methods of drainage in general use: (i) tubular 
drainage; (2) capillary drainage; (3) a combination of tubular and 
capillary drainage. All these methods have their advocates and are 
applicable under certain circumstances. No one method of drainage 
will answer in all cases. 

"Tubular Drainage. — Tubular drainage is specially indicated in 
cases in which the abdominal cavity contains pus. The tubes employed 
are made of either glass or soft rubber. Keith's glass drains answer an 
excellent purpose in draining the lowest portion of the abdominal cavity. 
They should be slightly curved at the abdominal end, so as to reach the 
floor of the pelvic cavity without making harmful pressure against the 
bladder. Frequent aspiration of the contents of the drain is necessary 
for the purpose of removing the fluid inflammatory product as soon as 
it is formed. 'The rubber drain answers the same purpose, but it is 
properly accused of causing more mechanical irritation than the smooth 
glass tube. Prolonged tubular drainage has not infrequently caused 
intestinal fistula by pressure. It is for this reason that I almost invariably 
surround the rubber or glass tube with a few layers of iodoform gauze 
securely fastened to the tube. In draining the pelvic portion of the 
abdominal cavity I frequently use two drains the size of the little finger, 
one on each side, brought out through the same opening in the lower 
angle of the wound. In draining the lumbar regions and through the 
vagina rubber drains should be employed. 

"Capillary Drainage. — Capillary drains are frequently employed 
as substitutes for the tubular drains, and, in addition, must often be 
relied upon as an important hemostatic resource in arresting parenchy- 
matous oozing. Iodoform or sterilized gauze is usually employed as a 
capillary drain in draining the abdominal cavity for peritonitis. Bar- 
denheuer first resorted to strips of iodoform gauze in draining the peri- 
toneal cavity. The greatest objections to this method of drainage are 
the danger from iodoform poisoning if a considerable quantity of gauze 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 255 

is used, the difficulty of removing the gauze, and the likelihood of a 
ventral hernia as a legacy. 

"The Mikulicz Drain. — The name of Mikulicz is connected 
with a special method of gauze drainage of his own device, familiarly 
known as the Mikulicz iodoform gauze or tampon or drain, which has 
proved of the greatest value in abdominal operations and in the surgical 
treatment of peritonitis. The typical Milkulicz tampon is made by 
taking a piece of iodoform gauze the size of a large handkerchief, to 
the center of which a strong piece of aseptic silk thread is stitched. 
When used, it is arranged as a pouch and is carried by means of a curved 
forceps to the bottom of the pelvis and filled with strips of iodoform 
gauze, the free end of the silk thread issuing from the mouth of the 
pouch. When it is desired to remove the drain, the gauze strips are 
removed and the pouch removed by making traction upon the string. 
Mikulicz speaks of an iodoform gauze drain, and any surgeon who has 
had considerable experience in abdominal surgery can testify to the 
fact that when the Mikulicz drain is called for we are frequently dealing 
with large cavities requiring an enormous amount of gauze. It is in 
such cases that we must learn to fear iodoform gauze, because the 
cases are by no means isolated in which a gauze drain composed exclu- 
sively of iodoform gauze has been the immediate cause of death from 
iodoform intoxication. This is particularly liable to occur in cases 
in which the patient's kidneys are not functionating properly or are 
diseased. It is in dealing with this class of cases that the elimina- 
tion of iodoform is accomplished with great difficulty, and hence when 
accumulation occurs, death is liable to follow from intoxication. Again 
there are persons who are extremely susceptible to the local and general 
toxic effects of iodoform. A very small quantity of this substance 
may prove fatal from intoxication. It is, therefore, advisable, in using 
the Mikulicz drain, to limit the iodoform gauze to an outer layer or two 
and pack the pouch with ordinary sterilized gauze. Drainage by using 
sterilized wicking has been popular in Germany for a number of years, 
and in many cases has answered an excellent purpose. It has never 
found its way to any extent into America, where gauze is employed 
in preference." 

A most excellent method of securing capillary drainage has been 
described by R. T. Morris. To avoid the danger of hard and soft 
tubes and of unprotected gauze, he recommends wicks, which he employs 
in a peculiar way. The simplest wick consists of a little roll of absorb- 



256 POSTOPERATIVE TREATMENT. 

ent bichlorid gauze, around which are wrapped a couple of thicknesses 
of Lister's protective silk. The gauze protrudes a little from each 
end of the cylinder, and a few small fenestra in the protective silk allow 
the serum to reach the gauze elsewhere. In certain cases in which injec- 
tions through a tube are desirable, the soft tube may be surrounded 
by this wick. When a large gauze packing for the pelvis or abdomen 
is needed, an apron of the silk can expand over the gauze and protect 
against intestinal adhesions. This method of drainage possesses great 
advantages over ordinary tubular and capillary drainage as heretofore 
described, and recommends itself more especially in the surgical treat- 
ment of diffuse septic peritonitis. The prolonged contact of gauze 
with a serous surface is very prone to give rise to permanent adhesions, 
as every clinician knows. In employing gauze in draining the peri- 
toneal cavity it is necessary to use long strips, which should be inserted 
some distance in different directions and brought out at the same place 
and fastened together with a safety-pin. Van Hook has shown by 
his experiments that the gauze drains more freely if the external ends 
of the strips are left long and placed on the side of the pelvis below the 
level of the wound. 

Drainage must be dispensed with as soon as possible, in order to pre- 
vent adhesions and to enable the surgeon to close the incision by secon- 
dary suturing, an important precaution against the formation of a ven- 
tral hernia. The strips should be shortened, and one after the other 
removed as the indications for drainage disappear. 

Combined Tubular and Capillary Drainage. — The simultaneous 
use of a tubular and capillary drain is an excellent method of securing 
drainage. It is made by packing loosely a glass drain of proper length 
and size with strips of gauze or aseptic wicking. This manner of drain- 
age is especially useful when the inflammatory product is serum instead 
of pus. It does away with the annoyance and risks of removing the 
transudate at frequent intervals, as is necessary in the employment of 
simple tubular drainage. If it is the design of the surgeon to resort 
to frequent irrigation after the operation, tubular drainage is necessary, 
but to this can be added capillary drainage by inserting strips of gauze 
into localities that would not be reached by the irrigating fluid. 

HERNIA. 

Operations for the radical cure of hernia are usually performed 
under aseptic precautions. The after-dressings consist of iodoform gauze 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 257 

or a pad of plain gauze or lint, or the wound is hermetically scaled with 
collodion. In very fat subjects a small gauze drain at the lower angle 
of the wound should be introduced and allowed to remain for two 
days, to avoid the accumulation of serum. In the great majority 
of cases, however, no drainage is necessary. An abundance of gauze 
dressings is applied, over which a bandage is carefully placed, not 
only around the pelvis, but around the limbs. Some surgeons also 
use an elastic bandage on the outside of the dressings. This is applied 
in the form of a figure of 8 around the limbs and pelvis. 




Fig. 74. — Double Spica Bandage. — (After Bassini.) 

If the dressings become soiled, or there seems to be excessive oozing, 
they should be changed promptly. To prevent the dressings becom- 
ing soiled, guttapercha tissue or a piece of faconet may be fastened over 
the dressing in such a manner as to prevent any dribbling of urine. 
In young children it is best to put on a fixed dressing with collodion. 

The imbrication or overflapping method of E. Wyllys Andrews is 
now most generally adopted by Western surgeons, in the radical cure of 
hernias. Posterior imbrication appeals to those who prefer the Bassini 
method, whereas the anterior imbrication is adopted by those who 
object to "transplanting the cord." In scrotal hernias the "sac" 
should be removed if easily separable, if not, cut off the part in the canal 
and return the scrotal part to the scrotum. If this is done a gauze 
or Mikulicz drain should be inserted through and out the lower part 
17 



2 5 8 



POSTOPERATIVE TREATMENT. 



of scrotum, or if preferred Eisendrath's method of "evertion" as in 
operations for hydrocele may be employed. Otherwise postoperative 
hydrocele requiring subsequent tapping, or other complications retarding 
recovery may ensue. If after ligation the peritoneal stump lies visible 
in the ring, it is too long and will form a funnel or dimple and tend to 




External 

oblique 

aponeurosis. 

Internal ob- 
lique muscle. 



Neck of sac. 

Internal ob- 
lique muscle. 

Rectus. 

Spermatic 

cord. 



Fig. 75. — Showing Russell's Method of Suture of Rectus Muscle to Poupart's 
Ligament Before Bringing Down and Suturing the Internal Oblique. 



bring on another protrusion. If stump does not disappear remove 
more of it. 

Skin Closure. — After very thorough hemostasis, sew the skin with a 
trocar-pointed needle. The following form of buttonhole continuous 
suture will please those who have not seen it. 

After the first knot, thrust the needle through both flaps about 1 
cm. from their edges. With the skin thus transfixed, wind the slack 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 



2 59 



of the thread twice around the point, instead of once, as in the ordinary 
lock-stitch. Then draw it up until it is just tight between the stitches, 
but does not pucker. 

There is no back-slip, and each stitch holds by friction. This gives 
a ridge-shaped suture-line like a double row of stitches. 

Do not drain these wounds, except in rare cases where there is much 
dissection and persistent oozing, when it is well to insert a small drain 
through an independent buttonhole — not through the angle of the 
incision. 

Seal the wound with collodion. Firmly bandage both groins with 




Fig. 76. — Blake's Method for Radical Cure of Femoral Hernia. 

wide spica bandages. In children and restless patients it is sometimes 
well to pad the hips, trunk and thighs with antiseptic cotton, and put 
a light cast or starch bandage from the chest to the knees. 

There is no advantage in redressing these cases. They are well on 
the eighth or tenth day, and should be allowed to be up and take ordinary 
exercise at once. Let no binder or truss be used after discharging the 
patient. (E. Wyllys Andrews.) 

After-treatment. — The patient should observe the recumbent position, 
and must avoid all exertion and straining during the period of conva- 
lescence. He should not be allowed to lift himself in bed. It often 



260 



POSTOPERATIVE TREATMENT. 



happens that the comfort of the patient may be increased by allowing 
the thighs to be kept a little flexed, by introducing a pillow beneath 
the knees. In male patients retention of urine is occasionally com- 
plained of. 

The dieting of the patient should be upon the lines observed in the 
after-treatment of cases of abdominal section. Opium should not be 
administered unless distinctly indicated. The bowels should be opened 
on the fourth day by an enema, unless previously relieved. Flatulent 




Fig. 77. — E. Wyllys Andrew's Operation Fig. 78. — Imbrication of Lower 

for Hernia. Segment of External Oblique. 

Mattress deep stitches in posterior imbrication. 

A . Externa] oblique. B. Cord lifted. C. 

Lower flap of external oblique. 

distention of the belly may be relieved by the use of the rectal tube,, 
or, if severe and persistent, by means of a saline aperient. In some 
rare cases a severe diarrhea sets in within a day or so of the operation,, 
and is not only very difhcult to cope with, but may soon lead to death 
from exhaustion. 

The drainage-tube, if employed, should be removed within forty- 
eight hours in ordinary cases that are doing well. The sutures maybe 
taken out on the eighth day or later. The wound should be dressed 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 



26l 



whenever the bandage becomes loose, and the parts around must be 
frequently washed with hydrogen dioxid or alcohol, and kept scrupu- 
lously clean and dry with powdered zinc stearate. 

The patient should not be allowed to get up until three weeks have 
elapsed after the operation, and then only if the wound is sound. The 
question of a supporting bandage or a truss will then have to be con- 
sidered. If the surgeon has been able to perform a radical cure at the 
time of the herniotomy, no truss need be worn, otherwise a light truss 




Fig. 79. 



will be required. In the case of a large femoral hernia it is difficult to 
prevent recurrence, and hence a truss is usually advisable. 

Complications. — The most important complication occurring during 
convalescence is suppuration, which takes place occasionally, and 
varies in extent according to the method of the operator, and is generally 
attributed to faulty disinfection of the deep stitches or suture material 
or undue suture pressure. This may be so, but we are by no means sure 
that the infection is not more frequently due to incomplete disinfection 
of the skin or some faulty manipulation on the part of the surgeon or 
his assistants. However that may be, suppuration after radical cure 
very seriously interferes with the result of the operation. Separation 



262 POSTOPERATIVE TREATMENT. 

of the tissues takes place in practically all cases in which suppuration 
occurs and the wound does not heal until all septic suture material is 
absorbed or thrown off. As this may take a long time, the inguinal 
canal becomes infiltrated with inflammatory cells and converted into 
cicatricial tissue which yields gradually before the weight of the abdom- 
inal contents. Hence the sooner the septic stitches are removed 
the better, and we would advise that whenever the accident has occurred, 
the wound should be opened up, either by turning aside the original 
flap or, in some cases better, by a second smaller incision over Pou- 
part's ligament, so as to expose the lower end of the deep stitches, which 
are found and removed; in this way much time is saved. (Cheyne.) 

It sometimes happens that, long after the wound has healed and the 
patient has been about, a small vesicle forms in the scar and leaves a 
sinus leading down to a stitch; this has happened even many months 
after the operation, and the sinus will not heal until the stitch concerned 
has escaped or has been removed. The cause of this is not quite clear. 
It may be some peculiar quality of silk or it may be due to some slow- 
growing nonpyogenic organism introduced along with the silk at the 
operation, or, again, it is conceivable that the tissues around the stitch 
become infected from the blood at a later period, when the patient's 
resisting power is not good. Fortunately, in our experience at any 
rate, this is an excessively rare occurrence, and need not be taken into 
consideration. Various applications have been suggested to prevent 
stitch abscess. Our hernia cases seem to do best without overprepa- 
ration. Just before the operation a simple but thorough scrubbing of 
the skin after the hair is removed is all that is requisite. The steriliza- 
tion of the deeper surfaces of the skin is very difficult, if not impossible, 
hence the application of mercurial ointment, soap poultices, and all 
such methods only tends to increase the danger of infection, or at least 
favors dermatitis. When we have reason to believe that sepsis is almost 
inevitable after careful preparation of the skin, a. Murphy dam should 
be applied to cover the entire inguinal region and genitalia, the dam to 
remain in position until the sutures are inserted and tied, after which 
it is lifted at one end and divided at or near the points of suture. 

According to Kelly, unnecessary handling of the wound, rough 
retraction of the skin edges, or prolonged pressure with metal retractors, 
carelessness in checking bleeding in the wound, strangulation by tying 
the ligatures too tight or too close together, all conduce to the forma- 
tion of stitch abscess. 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 263 

Of the many plans adopted for the prevention of stitch abscess, we 
will mention only that of Blondel. He makes as few stitches as possible 
through the skin, and before drawing them tight he wipes the sutures 
and edges of the wound with 90 percent alcohol, and sponges the tissues 
with gauze dipped in it. Each suture is treated in the same manner 
before tying, and after the w r ound is closed it is dusted with xeroform, 
iodoform, or equal parts of dermatol and aristol. Alcohol dries the 
surfaces better than any other substance. Its effect on grease is also 
a factor in the result, and it has a coagulating effect on the serum and 
thus favors cicatrization. 

POSTOPERATIVE HERNIA. 

General Considerations. — Postoperative hernia is much more 
common than is usually supposed. It may follow faulty technic or 
closure of the abdominal incision. In the majority of instances it 
occurs in cases in which drainage has been used. This is because the 
drain separates the fascial sheaths of the recti muscles and other sur- 
faces which otherwise would immediately unite. The small opening 
thus made in the wound increases, and hernia results. It is one of the 
most distressing sequels, causing the patient constant discomfort when 
erect, limiting to a great degree her activity, and even endangering life 
from incarceration of the bowel in the sac. It was far more frequent 
in the days when the abdomen was habitually drained after the opera- 
tion. "Hernia is more frequent in women, who become stouter after 
operation, and in whom the intraabdominal pressure is increased." 
(Kelly.) 

The employment of silver filigree as an additional aid or support 
to the abdominal walls in the treatment of large postoperative hernias 
is now considered of great value by many surgeons. There is no exact 
procedure applicable to all cases, but the method devised by Willard 
Bartlett, of St. Louis, Mo.,* is now generally accepted. 

The technic is as follows: Dissect away the old skin scar, which 
is usually wide, irregular and unsightly. 

Widely open the sac, reduce its contents, divide adhesions and 
excise the omentum when necessary. 

The excess of the sac is next trimmed away, and the resulting edges 
sutured with catgut in much the same manner as would be done in 
closing the healthy peritoneum. 

*Vol. xlvii, No. 10, "Jour. A. M. A." 



264 POSTOPERATIVE TREATMENT. 

It is now exceedingly easy to separate peritoneum and transversalis 
fascia from the posterior surface of the muscles; on the bed thus formed 
by fascia, a filigree, slightly longer than the opening, is placed and held 
in position by two sutures at its extremities. If the defect is a large one, 
it will now be found impossible to reunite the edges of any structure, 
but the skin, however, does not matter. All that is necessary is 
that the edges of the network should be covered for a short distance 
with a continuous catgut strand. The muscles and fibrous sheaths 
are partially drawn together in a single layer. Over this, fat and skin 
are closed in the ordinary manner. The patient is kept in bed for from 
two to three weeks, according to the necessities of the individual case, 
and a binder is worn for two or three more. 

Where drainage is necessary, Bassini's method of making a counter- 
opening or a stab wound to one side, through which a drain may be 
conducted without in any way interfering with or disturbing the solidity 
of the portion of the abdominal wall which it is desired to keep strength- 
ened. 

The Cause of Postoperative Hernia. — In an effort to ascertain 
the cause for the development of hernia following abdominal opera- 
tions, Wolfe has tried the various kinds of sutures and suture materials, 
as well as different forms of abdominal binders after operation with- 
out being able to discover that they bear any direct relation to this sub- 
ject. A careful study of the histories of patients seemed to demonstrate 
that hernia occurred most frequently in the cases in which pronounced 
abdominal distention developed within the first few days after opera- 
tion, regardless of the method by which the wound was closed. The 
distention probably acted as a direct factor in the production of hernia 
by causing the fascial sutures to yield or cut through. Abdominal 
distention and abdominal hernia developing shortly after operation 
seemingly stand in the relation of cause and effect. 

Since making these observations two years ago the author has closed 
completely only those laparotomy wounds in which an absolutely uncom- 
plicated course would be expected. In all other cases, in which more 
or less secretion could be expected, in which the peritoneum was trau- 
matized, or in which only a mild recent inflammation was found, he 
introduced a small iodoform gauze drain and thereby prevented post- 
operative meteorism. Since adopting the above plan the author is 
convinced that the sutures retain a firmer hold and hernia develops 
less frequently. 



LAPAROTOMY AND OPERATIONS UPON THE ABDOMEN. 265 

After operations on hernia developing in the linea alba, the intra- 
abdominal pressure and the lateral traction of the transverse and oblique 
abdominal muscles weaken the newly formed scar tissues and favor 
a return of the hernia. 

Of the 14 cases of postoperative hernia that have come under my 
personal observation, 12 followed superficial infection of the abdom- 
inal wound after laparotomy, and 2 followed prolonged drainage in 
appendicular abscess. Of the 12 laparotomy cases, the hernia occurred 
in the linea alba or line of incision, following the use of the subcuticular 
silver wire suture, and 7 were found to be devoid of the peritoneal 
covering, i.e., the edges of the peritoneum had been widely separated, 
the protruding bowel being held in position solely by the muscles and 
fascia. In the other cases (5) the peritoneal sac was unusually large. 

Operations for postoperative hernia differ only from ordinary 
hernia, (1) in the removal of all scar tissue; (2) the redundant sac of 
peritoneum, if present, should be removed, and the edges overlapped, 
as recommended by Andrews; (3) in the absence of the peritoneal 
covering, the peritoneum must be found and bluntly freed, dissected, 
or loosened well back from the adherent tissues. The edges must be 
freshened and lapped or closely approximated. This is often a very 
difficult matter, and if there is great tension or difficulty of approxi- 
mation, retentive button sutures of silkworm-gut passing through the 
entire thickness of the abdominal walls should be used as a matter 
of additional reinforcement. A blunt-pointed round needle should be 
used, in the insertion of the sutures, and the edges of the intermediate, 
subcutaneous, and cutaneous tissues carefully freshened before closing 
the incision. 

In order to obtain a firmer scar at the site of operation, Menge devised 
a new method, which he has employed in two cases with very satis- 
factory results. The hernia is exposed by a transverse incision and 
the hernial sac is extirpated. The anterior layer of the sheaths of the 
recti muscles is then divided by a transverse incision extending from 
each side of the hernial ring outward for a distance of three centimeters 
beyond the inner edges of the separated recti muscles. The recti are 
then dissected free from the anterior and posterior layers of their sheaths, 
care being taken to avoid unnecessary injury to the bloodvessels. The 
anterior and posterior layers of the sheaths are then separated from one 
another above and below the hernial ring, and from the recti muscles 
inward to the median line by means of the forefinger. In the median 



266 POSTOPERATIVE TREATMENT. 

line the two layers are too firmly united to permit of their separation 
by blunt dissection, but this can be accomplished by sph'tting them with 
a knife for a distance of three centimeters above and below the hernial 
orifice. The posterior layer of the rectal sheath is now sutured trans- 
versely, the mobilized edges of the recti are brought together and sutured 
in a longitudinal direction, the anterior sheath of the recti is closed trans- 
versely, and the fat and skin are united in separate layers by continuous 
sutures. By this method of forming flaps, longitudinal pulls on the scar 
are expended on the intact fibers of the recti, lateral pulls are resisted 
perfectly by the two layers of the sheaths of the recti, and a tendency 
to the recurrence of the hernia is thereby greatly diminished. 

u 

UMBILICAL HERXL*. 

Postoperative Treatment Mayo's Method . — In very large pro- 
trusions in which part of the hernial contents are irreducible the patient 
must be kept in bed on a reduced diet for several weeks, and directed 
to manipulate the hernia with the intention of replacing the hernia as 
much as possible. The irreducible portion must not be forced into the 
abdominal cavity after losing the right of habitation. If very fleshy, 
the hernia large, with a view to the reduction of weight, the patients 
are placed upon a restricted diet for several weeks ; purgatives are fre- 
quently administered and the entire intestinal tract emptied as far as 
possible. After the operation the ordinary dressings are applied — 
sometimes superficial drainage for forty-eight hours. The patients 
are kept in bed from three to four weeks upon a light diet, and after 
getting about are not allowed to apply a truss, although most of them 
prefer to wear an ordinary abdominal elastic supporter for a year. 



2HAPTEP XII. 

OPERATIONS UPON THE UTERUS. VAGINA 
BLADDER. AND KIDNEYS. 



CHAPTER XII. 

OPERATIONS UPON THE UTERUS, VAGINA, BLADDER AND 

KIDNEYS. 

ABDOMINAL HYSTERECTOMY. 

After-treatment. — The finished operation of abdominal hyster- 
ectomy should leave the peritoneum of the pelvis completely closed 
and the cervix representing the stump of the operation well buried 
beneath the serous membrane. The operation when completed 
should show the bottom of the pelvis smooth, free from bleeding points, 
and with the peritoneum intact at all places. The toilet of the peri- 
toneum and the closure of the wound are the last steps in the operation. 
After removal of all blood from the bottom of the pelvis the large gauze 
packs should be carefully removed, the intestines should be replaced 
in the bottom of the pelvis, and omentum spread carefully over the 
surface of the wound. The operation being performed under strict 
asepsis, these patients, as a rule, recover rapidly from the operation. 
They should be stimulated with normal salt infusions and by strychnin, 
and reaction established as early as possible by the application of dry 
heat, etc. Retention of urine is quite common after this operation. 
Every 7 effort, however, should be made to have the patient pass urine 
voluntarily, the catheter being used only under strict asepsis as a last 
resort. After the first twenty-four hours attention should be given to 
proper nourishment of the patient, the prevention of meteorism, etc. 
Further after-treatment is practically the same as for laparotomies in 
general, to which the reader is referred. 

VAGINAL HYSTERECTOMY. 

After-treatment. — Martin, who uses the forceps and clamp method, 

states that patients after a vaginal hysterectomy are treated in the 
same way as after an abdominal incision. The one exception to be 
made is in the management of the bladder. On account of the dressings, 
the patient should be catheterized until after the forceps are removed. 
The dressings are not disturbed until it becomes necessary to remove 
the forceps, and then only the external dressings. 

269 



270 POSTOPERATIVE TREATMENT. 

The forceps are removed in sixty-two hours in the following manner: 
The external dressings and wrappings are removed from the handles 
of the instruments and the silk securing the handles is cut. Without 
disturbing the dressings any more than is necessary the lock of the 
forceps is then opened, and the blades separated so that the pressure 
is taken off of the tissue in the grasp of the blades, but the forceps are 
not removed immediately from their location. The forceps of the 
opposite side are treated in the same way, the blades being separated, 
and then the operator waits for at least fifteen minutes, in order to make 
certain that hemostasis is secure. If for any reason a rush of blood occurs 
during the period of waiting, it is only necessary to lock the forceps, 
and, as they have not been disturbed, one is very sure that no harm 
can come as a result of this relocking. After the end of fifteen or 
twenty minutes the forceps may be carefully removed, the dressings 
cut off level with the vulva, and an abundant supply of soft, fresh, 
perineal dressings applied. Twenty-four hours after the removal of 
the forceps the packing is removed from the entire handkerchief. Twen- 
ty-four hours after this, vaginal douches of sterile water or boric-acid 
solution may be employed, great care being observed to keep the reser- 
voir low in order to avoid pressure, and also to secure a good and com- 
plete return flow immediately so as to run no risk of distending the 
vagina and causing the entrance of fluid into the abdominal cavity. 
From this time on douches may be employed, and later antiseptic 
douches of mercuric chlorid, or other materials, may be used as 
indicated. Patients are allowed to urinate after the forceps are 
removed, care being maintained to renew the dressings after each 
urination. 

Suture Method. — Kelly states that when the effects of the anesthesia 
have worn off, it is not necessary to keep the patient on her back. She 
will be greatly relieved from time to time by being gently turned over 
on one side or the other; after a few days she may turn on her face 
and urinate in this posture. At first the catheter should be used three 
or four times daily. The bowels should be moved on the third day 
by a laxative pill, followed by a warm enema of oil and soapsuds, or 
of glycerin and oil, 180 c.c. (6 ounces). During the evacuation she 
must avoid straining. If the fecal matter does not easily pass out, 
the nurse must assist with her fingers. After this, a movement must 
be secured every other day. The diet during the convalescence should 
consist for the first two or three days of liquids, followed by soft foods, 



OPERATIONS UPON UTERUS, BLADDER, KIDNEYS, ETC. 27 1 

nourishing soups, toast, soft-boiled eggs, oyster soup, various starchy 
foods, etc. 

Pain following the operation is often entirely absent and is rarely 
unbearable. Hypodermatics of morphin should be used sparingly to 
relieve severe pain during the first twenty-four hours. 

If the pack continues dry, and there is no discharge from the vagina, 
it may be left there five days longer. To remove the pack the patient 
is brought with the buttocks to the edge of the bed with the thighs 
flexed. The operator slips a narrow Sims speculum into the vagina, 
retracting the posterior wall, and with dressing forceps draws the 
strips of gauze out from between the ligatures. As soon as the strips 
are removed the vaginal vault must be cleansed with pledgets of absorb- 
ent cotton, and a fresh pack inserted. 

No vaginal douches of any kind should be used until three weeks 
have passed, when a 3 percent warm carbolized douche or boric-acid 
douche may be given once or twice daily, using a short nozle and taking 
great care not to push it too far in. When silk ligatures are used, the 
discharge is sure to become odorous sooner or later, and the vagina 
must be cleansed more frequently. The ligatures loosen and come 
away with a little traction in bunches, in from four to six weeks. It 
is a good plan not to wait for them to become detached, but in trife 
course of three weeks to expose and remove them with forceps and 
scissors. These sutures can be removed most easily with the patient 
in the knee-breast or the Sims posture. 

Convalescence. — After eighteen days the patient may sit in a reclin- 
ing chair a little while each day, and after this gradually increase her 
movements, until after four weeks, when she is usually able to be up 
all day. At this time an examination will show that the vaginal vault 
is closed, and the wound area has contracted dowTi to a transverse 
granulating linear scar, with the granulations more abundant at each 
end. After six or eight months this whole line has contracted still 
more, until it is a thin white cicatrix closing the vault. 

After a hysterectomy the patient should avoid hard work, heavy 
lifting, and prolonged exertion for several months. Recovery of health 
is usually rapid; within a few months a pale, emaciated woman often 
regains all her lost vigor. But the surgeon still has a duty to perform 
in continuing to watch these cases, examining them at first at intervals 
of two or three months, and later every six months, in order to detect 
at once any recurrence of the disease. It will occasionally be neces- 



272 POSTOPERATIVE TREATMENT. 

sary to cut out a small area of recrudescence in the vaginal vault, which 
will be detected at an early stage by this careful inspection. 

ALEXANDER'S OPERATION FOR RETROVERSION. 

After-treatment. — Immediately following the operation the patient 
is placed in bed, preferably in the prone position, or if the posterior 
vaginal vault has been well packed with gauze and the fundus of the 
uterus held well upward, the patient may be turned very gently upon 
either side. General restlessness or constant turning or changing 
of the position very frequently results in such tension upon the tissues 
as to cause stitch abscess or necrosis of the tissues, with subsequent 
suppuration, hence the patient should be cautioned regarding unnec- 
essary movements, and morphin used for pain or to enforce quietude. 
The operation is usually performed under strict asepsis, and healing 
by first intention is the usual result. The operation being extraperi- 
toneal is seldom accompanied by serious complications. 

The general treatment as to diet, etc., is the same as following a simple 
herniotomy. The stitches should be removed on the ninth day, and if 
there is no suppuration or other evidence of sepsis, the wound should 
lie dressed in the usual manner. If at any time septic symptoms are 
manifest, sufficient stitches should be removed to relieve tension, after 
which the treatment is the same as for that of ordinary septic wounds 
heretofore described. 

TRACHELORRHAPHY. 

After-treatment. — The following points laid down by Emmet are 
essential to proper healing, and necessary to secure satisfactory results : 
The cicatricial plug in each angle must be completely removed. The 
strip of mucous membrane left in the median line, which is to serve 
as the mucous lining of the restored cervical canal, must be of sufficient 
width to prevent stenosis. Sufficient tissue should be removed on each 
side of both lips to allow them to come into apposition without tension. 
All the sclerosed tissue must be removed. 

For about ten days after the operation the patient is kept in bed, 
and not allowed even to sit up. This may seem to be unnecessary 
caution, but when we consider the dragging down of the uterus which 
occurs during the operation, this period of rest seems only' prudent, 



OPERATIONS UPON UTERUS, BLADDER, KIDNEYS, ETC. 273 

even though the healing process were proceeding satisfactorily. Dur- 
ing this period carbolized douches are employed to preserve cleanli- 
ness, the bowels are kept regular, and she is allowed to pass her urine 
voluntarily if possible. After any operation the catheter should be 
avoided as much as possible, for its use is very prone to cause irritation 
of the bladder, which may easily prove more annoying than the opera- 
tion itself. I do not allow the catheter to be passed by touch alone, 
but insist that the urethra and adjoining parts be thoroughly cleansed 
and then the catheter introduced by sight. 

Removal of Sutures. — The usual custom is to remove the sutures 
at the end of about ten days, but my habit for some time past has been 
to examine the patient with the Sims speculum at the end of this time, 
and if the stitches do not appear to be causing irritation or are not in 
danger of cutting through, they are let alone, and the patient is allowed 
first to sit up, and then to walk around. If she menstruates within 
a short time, it is best to leave the stitches in until this is past. After 
this they are removed, the vagina cleansed, and a tampon of tannin 
and iodoform introduced. 

As regards the manner of removing the sutures, it is only necessary 
to say that the cervix is exposed with the Sims speculum, and with 
an ordinary uterine dressing forceps the stitch farthest away from the 
external os is grasped, and the suture cut, care being taken not to cut 
off the knot, for then it is almost impossible to find the suture. If 
the nearest suture is removed first, one is likely to tear open the cervix 
in removing the other less accessible ones. If the upper ones are 
removed first, and there should be a little oozing, the field of operation 
is obscured by the blood. After removing the stitches the sound is 
introduced to be sure that there is no obstruction in the cervical canal. 
The fissures left by the sutures will usually be obliterated in about a 
week. 

NEPHROTOMY AND OPERATIONS IN GENERAL UPON 

THE KIDNEY. 

In operations upon the kidney or urinary tract it is usually advisable 
to place the patient upon a course of salol 45 grains or urotropin 15 
grains daily for several days prior to the operation. 

Nephrotomy can be performed from the front or behind. The 
anterior incision recommended by von Bergmann is generally known 
as the lateral incision, although the chief part lies on the anterior aspect 
18 



274 POSTOPERATIVE TREATMENT. 

of the abdomen. For the majority of cases of simple nephrotomy 
the posterior oblique incision, as recommended by Czerny and others, 
may be regarded as the normal incision in the lumbar region, as it 
corresponds with the course of the vessels and nerves and gives the 
best access to the deeper parts. 
. In nephrorrhaphy the thin fibrous capsula propria of the kidney is 
incised and stripped from the organ so that a good grip of it may be 
included by the four to six sutures which are used to unite the capsule 
to the lumbar fascia. The exposed kidney substance lies at the bottom 
of the wound, which is ordinarily left open, healing taking place by 
granulation in order that firm scar tissue may extend from the skin 
to the kidney substance. In all operations upon the kidney where 
the substance of the kidney has been interfered -with it is almost neces- 
sary to treat the wound by the open method, not only on account of 
the escape of urine or the fear of a urinary fistula being formed, but 
also for the reason that the surrounding tissues are readily infected. 

If the pelvis of the kidney has been opened or if there is any indi- 
cation of infection, a tampon of iodoform or xeroform gauze should be 
inserted down to the pelvis of the kidney, or a drainage-tube inserted, 
after thoroughly washing out the pelvis and wound with sterile salt 
solution. If an ordinary drainage-tube is used, it should be surrounded 
with iodoform or xeroform gauze and fixed in position with a strip of 
gauze and collodion. The outer dressings require to be changed 
frequently. 

In operations for nephrorrhaphy or fixation of the kidney it is essen- 
tial that the cicatrization which follows should involve a considerable 
area of the kidney substance itself, for it is only in this way that certain 
and permanent fixation is possible. The endeavor to obtain union 
by first intention does not give as satisfactory results as the open method 
of treating the wound, complete healing by granulation requiring four 
to six weeks. 

In nephrectomy the method of removing the kidney depends upon 
the disease. If possible, the kidney should be freed in toto after all 
the large vessels entering the capsule have been carefully ligated and 
the structures at the hilus carefully isolated. The ureter, which lies 
lowest, is ligated last, the renal artery and vein being fixed firmly and 
tied. The wound may now be closed, two short glass tubes being 
introduced for twenty-four to thirty- six hours. 

When suppuration is present or infective processes exist, the ureter, 



OPERATIONS UPON UTERUS, BLADDER, KIDNEYS, ETC. 275 

unless it can be completely extirpated, is stitched to the wound. Excis- 
ion of the ureter is, however, always preferable, and the wound under 
these circumstances should be carefully packed with iodoform gauze 
and treated after the open method. 

After operations upon the kidneys the skin and bowels should 
be kept very active and the patient kept warm and comfortable. It 
is essential that the amount of urine passed should be carefully meas- 
ured, that any diminution in quantity may be detected at once. Should 
the skin around the wound become inflamed or sore from the secre- 
tion of urine or discharge, sterilized benzoated zinc oxid ointment 
should be used freely. Following nephrectomy, pain is sometimes 
very severe, requiring the use of morpin hypodermatically, but morphin 
when used in these cases should always be combined with digitalin 
in order to overcome the tendency toward diminution of urinary secre- 
tion. A complication of persistent vomiting, so common after opera- 
tions upon the kidneys, may be overcome by some of the methods here- 
tofore mentioned. A temperature of 103 to 105 F. is not uncommon 
after nephrectomy or operations upon the kidneys. This ordinarily 
should occasion no alarm, being reflex in character and supposed to 
be due to interference with or irritation of the sympathetic nerves. A 
subnormal temperature followed by a pronounced rigor is indicative 
of sepsis and calls for prompt examination of the wound. 

Abscess of Kidney. — After the evacuation of the pus and the explora- 
tion of the cyst, the kidney should be well flushed out with warm steril- 
ized water; a drainage-tube is then introduced up to the kidney. This 
is packed round with gauze, and the parietal wound is closed around 
the tube. 

In cases in which the kidney is found to be very mobile the organ 
must be steadied while the abscess cavity is being dealt with; and before 
the tube is inserted it may be desirable to secure the too movable gland 
in place by means of two or more deep sutures introduced into the renal 
tissue. The after-treatment of these cases differs in no essential from 
that indicated in nephrolithotomy. The tube should be shortened 
gradually, the dressings must be frequently changed, and the wound 
cavity be frequently and freely irrigated. 

OPERATIONS UPON THE BLADDER. 

Preparatory Treatment. — Before undertaking any operation upon 
the bladder (according to Ochsner) it is desirable that the urine should 



276 POSTOPERATIVE TREATMENT. 

be as nearly aseptic as possible. Measures should be taken to make 
the urine as nearly normal as the condition of the patient will permit. 
The condition for which the operation is performed usually predisposes 
to an abnormal state of the urine, and frequently not only the bladder 
but also the kidneys are diseased. If the urine contains septic material, 
this condition can be changed by dilution, the patient being given large 
quantities of distilled water, or, if this is not agreeable, one of the various 
mineral waters may be given in large quantities. This in itself will 
reduce the septic nature of the urine to a great extent. If the urethra 
is permeable to the passage of a catheter, irrigation of the bladder with 
a mild nonirritating antiseptic solution, such as a solution of boric acid, 
a 1 : 1000 solution of permanganate of potash, a 1 : 2000 solution of 
silver nitrate, saturated solution of aluminum acetate, or a solution 
of any one of a number of the recently produced silver salts, may be 
used to advantage. Care should be taken not to irritate the bladder 
with any of these solutions. If it is found that one irritates more than 
the other, it should be avoided. The bladder should be filled moderately 
full and then the fluid should be permitted to escape again, or the bladder 
may be irrigated with a constant stream through a double catheter, one 
tube serving the purpose of introducing the fluid, the other the purpose 
of emptying the bladder. A repeated examination of the urine will 
determine whether this treatment reduces the amount of septic material 
regularly found. 

There are a number of antiseptics which can be given internally 
for the purpose of disinfecting the urine. Of these, 5 -grain doses 
of boric acid given with half a pint of distilled water or mineral water 
every three hours; the same dose of salol, or of urotropin, or one-grain 
doses of methylene-blue given in the same manner, are probably the 
most useful. There is, however, this fact to remember, that urine 
usually is most septic if the bladder is not at any time completely 
evacuated, and consequently in these cases but a slight amount of benefit 
can be expected unless this residual urine is removed once or twice, 
or oftener, each day and the bladder carefully irrigated. 

Suprapubic Cystotomy. — After-treatment. — Ochsner states that 
the most important point in the after-treatment of these cases consists 
in giving the patient large quantities of pure water to drink. If the 
patient is at all shocked by the operation, it is wise to give saline trans- 
fusion at once or to give an enema of half a pint of normal salt solution 
every hour. The bladder is irrigated with a saturated solution of 



OPERATIONS UPON UTERUS, BLADDER, KIDNEYS, ETC. 277 

boric acid from two to six times a day, according to the character of 
the urine. 

Considerations of Technic. — If the operation has been per- 
formed for the purpose of securing permanent drainage, the incision 
should be made as near the os pubis as possible, and should be only 
just large enough for the purpose of permitting careful digital explora- 
tion. Several purse-string sutures should then be applied in order to 
prevent leakage, and a retention catheter introduced. The wound 
should be tamponed around this retention catheter and the stitches 
in the bladder wall should be passed through the edge of the wound 
and tied just sufficiently tight to hold the anterior wall in close apposi- 
tion with the abdominal wall. A few silkworm-gut sutures are then 
applied, so as to grasp the wound on each side, and to take a small 
bite in the anterior wall of the bladder above the point of incision, and 
two small bites, one on each side of the incision in this portion of the 
bladder. These sutures are left untied until the first dressing, which 
occurs a few days after the operation, when the gauze tampon and 
the three first stitches may be removed and the silkworm sutures may be 
tied, leaving only a space through which the drainage-tube passes. If 
the bladder has been in a septic condition, it is often best to pass two 
ordinary rubber drainage-tubes, one-half a centimeter in diameter, 
perforated with several small openings in the end, and these two rubber 
tubes should be sufficiently long for the ends to project into an anti- 
septic solution in a bottle tied to the side of the bed. It is then possible 
to irrigate the bladder by permitting the fluid to flow in through one 
of these tubes and out of the other; and in case one or the other becomes 
occluded with mucus or blood, the free one will suffice to drain the 
bladder. It is a good plan to insert a glass tube into the end of the 
rubber tube, so that its weight will keep it from becoming dislodged 
from the bottle. If the presence of the rubber tubes gives rise to pain, 
their position should be changed occasionally. (See Fig. 80.) 

If the operation is performed for the removal of a stone from a healthy 
bladder containing nearly normal acid urine, the wound in the bladder 
may be closed by a double row of catgut sutures, which are not per- 
mitted to penetrate the mucous membrane, however. The space 
between the bladder and the abdominal wall should always be drained 
thoroughly in these cases for fear of extravasation of urine. A soft- 
rubber retention catheter is placed into the bladder through the urethra 
in such instances and carefully fastened in place, so as to keep the 



278 



POSTOPERATIVE TREATMENT. 



bladder thoroughly drained. If there is any doubt about the asep- 
tic condition of the bladder, it does not seem wise to close the bladder 
wall completely, in which case the wound is treated after the open 




Fig. 80. — Showing Y Tube Used for Drainage and Irrigation after Supra- 
pubic Cystotomy. 

method, with fresh gauze packing daily, and healed from the bottom 
by granulation. 

Senn advises two stages in the operation in cases of septic cystitis: 






OPERATIONS UPON UTERUS, BLADDER, KIDNEYS, ETC. 279 

After the anterior wall of the bladder has been exposed and all hemor- 
rhage arrested, the wound is packed with iodoform gauze and the dress- 
ing held in place by strips of adhesive plaster; this dressing is allowed 
to remain for five days; at the end of this time the wound, if it has re- 
mained aseptic, is covered with a layer of healthy granulations, which have 
closed the connective tissue channels and have shut out from the wound 
the remainder of the prevesical space. As a second stage, with the 
danger of infiltration lessened by these favorable circumstances, the 
bladder is incised and drained in the usual manner; under this operation 
cocain is adequate without general anesthesia. In relation to this 
modification of suprapubic cystotomy Senn makes the following state- 
ments : 

"(1) Necrosis and phlegmonous inflammations of the margins of 
the wound and the tissues in the prevesical space (cavum Retzii) not 
infrequently occur as complications of suprapubic cystotomy if the 
operation is performed for affections complicated by septic cystitis. 
(2) Suprapubic cystotomy in two stages greatly diminishes, if it does 
not entirely overcome, this source of danger. (3) In the first operation 
the bladder is freely exposed. in the usual manner, when the prevesical 
fat is dissected away over a vertical oval space at a point corresponding 
to the location of the proposed visceral incision, after which the wound 
is packed with iodoform gauze and the external dressing is applied in 
such a manner that it cannot be displaced. (4) The incision in the 
bladder and the intravesical operation are postponed until the external 
wound has become covered with a layer of active granulations, which 
usually requires from four to six days. (5) The second operation 
can be performed with the aid of cocain without general anesthesia. 
(6) This modification of suprapubic cystotomy diminishes the immediate 
risks of the operation and affords protection against a number of serious 
postoperative complications." 

After-treatment. — (Method of Sir Frederick Treves.) If the 
wound in the bladder has been closed by sutures, the after-treatment 
of the case is conducted upon the lines observed after any ordinary 
abdominal section. The employment of the catheter, if the patient 
cannot pass urine, is imperative. A soft catheter should be introduced 
as often as required. The superficial sutures may be removed at the 
end of a week; and if all goes well, the patient may be sitting up in ten 
days. 

If the wound in the bladder has been left open, the after-treatment 



28o 



POSTOPERATIVE TREATMENT. 




Fig. 8i. — Stevenson's Suprapubic 
Drainage-tube. — (DaCosta.) 



becomes very tedious, and demands infinite care. The bed must be 

protected by mackintosh sheets, placed beneath the usual draw-sheets. 

A large cradle is spread across the 
pelvis. The care of the wound will 
demand the constant and undivided 
attention of a nurse. 

The skin of the perineum, buttocks, 
and lower part of the abdomen should 
be kept as dry as possible, and should 
be smeared with vaselin to prevent the 
irritating effects of the contact of urine. 

Over the wound should be placed a large sponge, and above the sponge 

should be a large pad of absorbent wool, applied transversely, like a 

scarf, from one side of the 

groin to the other. This 

pad rests upon the pubes. 

It keeps the sponge in 

place, and serves to absorb 

any urine which may escape 

the sponge. It may be con- 
veniently replaced by pads 

of cyanid gauze, frequently 

changed. Not less than 20 

sponges should be in use. 

The arrangement of the 

bed-clothes over the cradle 

allows the part to be always 

in view, the patient's trunk 

and limbs being well covered 

up with blankets. 

The sponges and wool 

pad must be changed as 

often as needed — possibly 

two, three, or four times in 

the hour. The pad is, of 

course, thrown away, but 

the sponge may be used over and over again. 

rinsed in water, is then immersed for some 

lotion, is once more rinsed, and is then dried ready for use. Before 




Fig. 82. — Stevenson's Suprapubic Drainage-tube 
in Place and Attached to a Receptacle for 
Urine. — (DaCosta.) 



Each sponge is well 
hours in carbolic 



OPERATIONS UPON UTERUS, BLADDER, KIDNEYS, ETC. 28 1 

each sponge and scarf of wool are applied, the skin should be rapidly 
dried. No bandage is required. The patient must lie upon the back, 
and should assume, as soon as he is able, the sitting position. If he 
wishes to lie upon one or the other side, the sponge and the wool pad 
must be adjusted to meet the altered position. 

If this plan is carried out by intelligent and painstaking nurses, the 
patient's bed may be kept absolutely dry, and the skin perfectly sound 
and free from excoriation. The sponges can be changed during sleep 
without waking the patient, the wound being always in view through a 
"window" in the cradle. The sooner the patient can sit up in bed, 
the better, as the wound is much more readily deal with when that 
attitude is assumed. Any "dressing" secured with a bandage round 
the body is useless. By the time the dressing has been applied and the 
bandage secured, the whole arrangement is probably soaked with urine. 
The bladder may, when necessary, be washed out with a boric-acid 
solution as often as occasion arises. 

Tempo rary Drainage. — A convenient form if there is not too 
much pus in the urine is provided by anchoring two large soft-rubber 
catheters together by suture through the eyelets, passing the double 
tube thus formed through the suprapubic wound and into the bladder. 
Each of these is connected to a rubber tube by means of a glass coupler. 
The tubes lead into a basin beneath the patient's bed. The advantage 
of this apparatus is that if one tube becomes blocked, the other will 
drain the bladder, and also irrigating fluid may be passed through one 
tube and the other will drain the fluid away. 

The bladder wound usually closes in two, three, or four weeks, and 
the external wound one or two weeks later. It is probable that the 
patient will be able to be moved into a chair by the end of the second 
or commencement of the third week. 

According to the late A. B. Craig, of Philadelphia, when permanent 
suprapubic drainage is necessary, one of the best forms of apparatus 
for this purpose is seen in Figs. 81 and 82. 

LITHOLAPAXY. 

After-treatment, according to Dennis, consists in rest in bed, milk 
diet, and moderate doses of quinin, salol, or boric acid. The average 
stay in the hospital after litholapaxy in adults is about ten days. Even 
calculi of large size are at the present day treated by litholapaxy. Buck- 



282 POSTOPERATIVE TREATMENT. 

ston- Browne has on several occasions crushed uric- acid calculi weigh- 
ing over three ounces, and also reports crushing a cystin calculus weigh- 
ing two and a quarter ounces ; such a weight of cystin indicates a calculus 
of large size, as cystin is a light substance. 

Keegan, after reporting 50 cases, which bring his total up to 175, 
with 5 deaths, lays down the following rules to guide the inexperienced 
in performing the operation of litholapaxy in boys : The surgeon should 
be provided with an ample supply of perfectly reliable lithotrites, all 
of the completely fenestrated pattern, and with cannulas with service- 
able stylets. He should never withdraw a cannula from the bladder 
nor introduce one unless it is fitted with a stylet. Four ounces (124 
grams) of water should be the maximum quantity allowed to be in the 
bladder at any given moment. The aspirator should be used gently 
and methodically, and water should not be injected into the bladder 
while the patient strains. Extreme gentleness and care are essential 
in practising all manipulations of instruments in the bladder and ure- 
thra. The operator should not be in a hurry to finish the . operation, 
and if possible he should not leave a grain of debris behind in the bladder. 
If all these conditions be fulfilled, a large measure of success will be 
obtained. 

Guyon in his last 49 cases of lithotrity has used a retained catheter, 
keeping it in place for twenty-four hours. In 40 of these cases there 
was absolute apyrexia, and in the other 9 merely a slight and transitory 
elevation of temperature. Of the patients, 27 had old phosphatic cal- 
culi, were obliged to empty the bladder by catheterism, and had been 
infected for a long time. Guyon remarks that, even admitting that 
fever and cystitis are rare after lithotrity at the present day, this experi- 
ence demonstrates that the retained catheter may be employed without 
causing vesical inflammation, as formerly thought to be an invariable 
consequence. My own experience would not lead me to think it nec- 
essary in the majority of cases, but his testimony would lead me hence- 
forth to employ a retained catheter after litholapaxy in old persons with 
infected and atonic bladders and with enlarged prostate. 

Sir Henry Thompson's Method of After-treatment. — The patient 
must lie in bed. An india-rubber hot-water bottle or warm fomen- 
tations may be applied to the hypogastrium. Some opium may be 
required. There may be some urethral fever, or retention of urine 
from atony of the bladder. Not infrequently subacute cystitis appears 
on the fourth or fifth day. The administration of urotropin or cys- 



OPERATIONS UPON UTERUS, BLADDER, KIDNEYS, ETC. 283 

tamin in 5-grain doses and the injection into the bladder of a few ounces 
of solution of silver nitrate (half to one grain to the ounce) are useful 
for this complication. The patient should be kept on a light or milk 
diet, and remain in bed until any cystitis has subsided. If the stone 
is small and there have been renal symptoms, the opportunity should 
be taken to exclude the existence of other calculi in either kidney by 
skiagraphy. A warm hip-bath daily adds greatly to the patient's com- 
fort. The urine contains no trace of blood, as a rule, after the second 
to the fourth day; and in the majority of cases the patient may be allowed 
to get up on the seventh day. An occasional and troublesome com- 
plication, occurring especially in adults, is orchitis or epididymitis. 

According to Freyer,* the average number of days spent in hospital 
or under treatment is, in adult males, six; in boys, five and a half; and 
in females, four. 

Results. — Sir Henry Thompson's cases of lithotrity since 1878 
number 378, including 325 treated each at one sitting. The mortality 
is a little over 3.5 percent. t 

Cadge expresses his belief that the relapses after simple lithotrity 
reach to nearly 20 percent, if the cases of phosphatic deposits and con- 
cretions common after -this operation are included among the examples 
of recurrence of the stone. Litholapaxy is attended with no such pro- 
portion of unsatisfactory results; and, indeed, if the evacuator be care- 
fully and thoroughly employed, the relapses after litholapaxy will prob- 
ably include no cases of recurrence due to the actual retention and 
subsequent increase of a fragment. 

PERINEAL LITHOTOMY. 

Dennis states that when the calculus has been extracted and the 
bladder has been explored for other chance calcareous deposits adher- 
ing to the walls, or for other concretions, the bladder should be thoroughly 
irrigated with moderately hot water to wash out any clots of blood 
which may have entered it, and also to stop any slight oozing from the 
edges of the wound. If the hemorrhage be considerable and the vessels 
cannot be ligated, the air-tampon or catheter en chemise should be 
inserted. The packing which is inserted within the cuff of the latter 
instrument may be removed at the end of two or three days. W. A. 

* " Brit. Med. Jour.," May 9, 1891. 
t " Med-Chir Trans.," 1890. 



284 POSTOPERATIVE TREATMENT. 

Mackay reports favorably on the use of glass tubes for drainage after 
perineal or suprapubic lithotomy associated with cystitis. To the end 
of the glass tube a soft-rubber tube is attached, and conveys the urine 
to a vessel beneath the bed, in which the end of the rubber tube is 
kept constantly submerged in an antiseptic fluid. The glass tubes 
should be slightly smaller in caliber than those ordinarily used in abdom- 
inal sections. No other dressing is used except light packing around 
the tube and a T-bandage in perineal cases. Drainage should be 
maintained until the urine becomes clear. 

When prolonged drainage is not deemed necessary and the hemor- 
rhage is not sufficient to demand packing the wound, then only a fight 
pad of iodoform gauze should be applied, but not pressed in so tightly 




w 

Fig. 83. — Lateral Lithotomy with a Curved Staff. — {Bryant.) 

as to prevent the free escape of urine through the wound, which will 
continue for a day or so, and then, owing to the inflammatory swelling, 
gradually cease. 

After-treatment. — The patient is placed on a narrow bed with a 
firm horsehair mattress, protected by a waterproof sheet. Beneath 
the buttocks are kept squares of old sheeting, which can be changed 
as often as they are wet with urine. In addition to the sheets, large 
sponges may be employed, to absorb the escaping urine. They can 
be readily changed without disturbing the patient, they are easily 
cleansed, and if plenty are employed, and each one is allowed to lie for 
some time in a carbolic solution before it is used again, the same 
sponges can be employed over and over again. They need to be well 



OPERATIONS UPON UTERUS, BLADDER, KIDNEYS, ETC. 285 

dried by heat before being applied, and may be dusted with 
iodoform. 

A rope and handle-bar suspended above the bed will enable the 
patient to raise his pelvis readily when the squares of sheeting are 
changed. The knees should be supported by separate pillows, with 
an interval between them. Nothing must obstruct the free exposure 
of the tube. Clots in the tube may be removed with a moistened 
feather. If the escape of urine ceases and there is pain about the bladder, 
the tube may be pushed a little further in, or a soft-rubber catheter 
may be introduced through it into the bladder. In most cases the tube 
may be removed in thirty-six or forty-eight hours. In some few in- 
stances — especially w r hen there have been difficulties of micturition 
previous to the operation — the tube may have to be retained for three 
or four days or even longer. 

The parts exposed to the contact of urine should be dried as fre- 
quently as is possible. The scrotum should be kept away from the 
perineum by a simple suspender or " crutch pad." When the urine 
is alkaline and irritating, the skin of the buttocks and perineum should 
be smeared well with vaselin after each change of sheets or sponges. 
In cases of actually putrid urine the bladder should be washed out two 
or three times a day with a warm solution of boric acid. The urine 
begins to flow by the urethra, as a rule, between the eighth and twelfth 
day, and the perineal wound is generally healed and the patient " cured" 
within four to six weeks. The same care in the diet is observed as is 
customary after all major operations. If the bowels are not opened 
by the third day, a laxative should be given. 

When secondary bleeding occurs, the patient should be placed once 
more in the lithotomy position, and the wound thoroughly cleansed 
and examined. The tube should be removed, and the clots washed 
out of the bladder. 

When the incision has been dried, it is possible that the bleeding 
point may be detected, especially if the perineum be in a good light 
and the wound margins be well retracted. In such a case pressure 
forceps will meet the complication. Failing the easy securing of the 
divided vessel, cold injections may be tried; but if they fail, as is most 
probable, the tube should be reinserted, and the wound plugged with 
gauze. Injections of powerful styptics, and especially of perchlorid 
of iron, are to be absolutely condemned. 

Complications. — The following complications may occur during the 



286 POSTOPERATIVE TREATMENT. 

after-treatment: Retention of urine from blocking or displacement 
of the tube. Suppression of urine in cases in which the kidneys are 
diseased. Incrustation of the wound with phosphates may occur 
when the urine is ammoniacal and there is much cystitis. This is espe- 
cially met in aged and feeble patients. The condition it met by fre- 
quent irrigation of the bladder with boric-acid lotion or mildly acidu- 
lated solutions, and by constant attention to the wound. Epididy- 
mitis is not infrequently met after lateral lithotomy. Cellulitis from 
urinary infiltration is, of all the possible complications, one of the most 
serious. It is fortunately uncommon. 

PERINEORRHAPHY. 

After-treatment (Martin). — After the operation the patient must 
lie in bed until the wound is sound and the sutures are all removed. 
This will represent a period of from fourteen to twenty-one days. The 
patient should be encouraged to lie upon the side. A cradle should be 
placed over the pelvis, the space under the bed-clothes should be venti- 
lated, and every opportunity be taken to change the heated and close 
atmosphere with which the wound must of necessity be surrounded. 

It is never necessary to tie the legs together, as was the barbarous 
and senseless custom at one period. No T-bandage is required. The 
wound is best dressed with iodoform. This may be liberally dusted 
over the part, the wound being left otherwise uncovered; or a "sani- 
tary towel" well treated with iodoform may be worn, and the wound 
be supported by the soft pad of the "towel." The part should be 
kept throughout as dry as possible. Some patients suffer excruciat- 
ingly after these operations — much more so, as a rule, than after ordi- 
nary laparotomies. Hypodermatics of morphin are frequently indis- 
pensable, but should be avoided when possible. Great difficulty with 
the bowels may result from the too free use of the drug. 

Catheterizing the Patient. — Almost any patient, if properly encour- 
aged, will be able to urinate without the use of the catheter, and clean 
urine will be less harmful to the perineum than the indiscriminate use 
of the catheter will be to the urethra. The patients, therefore, are 
requested to urinate, first removing the dressings from the perineum 
before the attempt is made, and the nurse is instructed to irrigate the 
perineum immediately after the urination with a saturated solution of 
boric acid, normal salt solution, or even sterilized water. 



OPERATIONS UPON UTERIS, BLADDER, KIDNEYS, ETC. 287 

Attention to the Bowels.— All patients should be prepared, prior 
to the operation, by a thorough evacuation of the intestinal canal. They 




Fig. 84. — Suture of Perineum after Martin's Method. — {Martin, by permission.) 

are kept upon liquid food for at least two days before the operation. 
The intestinal tract is rendered as aseptic as it is possible to make it. 
Twenty-four hours after the operation laxatives should be administered, 



288 



POSTOPERATIVE TREATMENT. 



assisted, if necessary, by mild stimulating enemas. No attempt to 
establish constipation should be made ; the bowels should move naturally 
from the first. 




Fig. 85. — Complete Closure of Perineum, showing Buried Suture Knots. — 

{Martin, by permission.) 

Care of the Perineum. — Besides dressing the perineum with pads 
of fluffy, sterilized gauze after each urination of the patient or move- 



OPERATIONS I PON ITKRIS, m.ADDKR, KIDNKYS, KTC. 289 

mcnt of her bowels, the perineum is, as indicated before, irrigated several 
times a day and the dressings replaced. 

A note must be made at the time of the operation of the number 
of sutures inserted, as it is not uncommon to find, when weeks have 
elapsed, that a suture has been overlooked. 

As the sutures are of silkworm-gut, it is necessary that they be removed, 
and their removal is accomplished on the twelfth day after the opera- 
tion. As the sutures are tied just within the skin-margin, the operator 
will find that the knots, after complete union has occurred, are buried 
beneath the skin. The removal of the sutures, therefore, is a point 
requiring considerable delicacy of treatment. After the sutures are 
separated and identified, one end of the stitch is grasped and gently 
drawn upon until the knot is brought through the opening made by 
the single suture. Then, by cutting beneath the knot on one side, the 
suture is easily withdrawn. It is well to remember this injunction, 
as it is a very difficult and painful procedure to attempt to cut beneath 
the knot unless it has been drawn through the skin. 

In the case of the complete operation, the perineal sutures are removed 
first, and the rectal sutures at a later period. The removal is in the 
reverse order to the introduction. A small rectal speculum will probably 
be required when the rectal stitches are taken out. 

The patient should be allowed to sit up on the fifteenth to the seven- 
teenth day, and gradually to get about at the end of the third or the 
beginning of the fourth w r eek. All patients should be instructed to use 
considerable care to avoid heavy physical work for several months. 

Howard Kelley's method of treatment following extensive plastic 
operation on rectum perineorrhapy, etc. 

1 . Let me say emphatically that I prefer to manage my complete tear 
cases by the starvation plan, for I believe it is the best way to manage 
them. 

One of the inherited gynecological traditions runs to the effect that 
if you lock up the bowels you are sure to have scybala form, and when 
these pass they wall tear open the wound. This difficulty can be 
controlled by diet. If you give milk, you will have scybala, but not 
with albumin. 

The following case illustrates the method I employ: Following the 
operation no food is given for 24 hours. 

The patient then received two drams of albumin in water at 9 
A. m. and again at 11:45 p. m. 
19 



290 POSTOPERATIVE TREATMENT. 

On the third day she received two drams of albumin, on an average, 
every three hours. 

On the fourth day, after receiving two drams every three hours for 
five times, she took four drams for the remaining three times. 

From the fourth day on, she received four drams every three hours 
until the tenth day, when I gave an oil enema, and on the following day 
administered licorice powder, 2 drams, followed the next morning by 
another oil enema, which in turn, was followed by 2 drams of the 
sulfate of magnesia, after which she had a large, partly formed stool, 
with no scybala. 

The result of the operation was perfect. 

In some of the earlier cases the diet was occasionally varied with 
a half-ounce of beef-juice or chicken broth, or 2 ounces of peptonoids, 
but it soon became evident that the patients did best, and that there was 
less difficulty with the bowels, on albumin alone, so that, for some time 
past, it has been consistently adhered to. 

The total amount of albumin taken by a patient who is thus locked 
up and put on limited diet during a period of ten days, is one quart 
and thirteen ounces; the amounts average as follows: First day, noth- 
ing; second day, 12 drams; third day, 24 drams; fourth day, 34 drams; 
fifth day, 48 drams; and from the fifth to the tenth day, 48 drams, or 
6 ounces daily; making a total of 45 ounces, or 1 quart, 13 ounces in 
ten days. 

The bowel is moved at the end of the period by giving a half-ounce 
of licorice powder, followed, in some cases, by an oil enema, and, perhaps, 
the next morning by a half-ounce of salts. 

The most important factor in securing the first evacuation is to 
have the patient lying on the side in a Sims position, so as to obviate 
straining. The nurse then takes one of the kidney- shaped pans, or a 
triangular pan, and receives the movement as it comes. One of my 
patients got onto a large bedpan in. this position; a rubber sheet and 
plenty of gauze can also be used, the evacuation passing onto the bed. 
As soon as the bowels move, I give broth, beef-juice, or wine jelly for 
twenty-four hours and then a soft-boiled egg and creamed sweetbread, 
and after this, bread, toast, soup. I keep the patients in bed, as a 
rule, for eighteen days. 

To follow out this plan of treatment takes much moral courage, as 
the patient at first begs, and even cries, for food.* 

* " Surgery, Gynecology and Obst," Vol. ii, No. 2. 



CHAPTER XIII. 

OPERATIONS UPON THE RECTUM, PROS- 
TATE GLAND, URETHRA, AND SCROTUM. 



CHAPTER XIII. 

OPERATIONS UPON THE RECTUM, PROSTATE GLAND, 
URETHRA, AND SCROTUM. 

HEMORRHOIDS. 

The postoperative treatment depends largely upon the method employed 
for the removal of the hemorrhoids. The ligature has been for many 
years the most popular method among surgeons for the treatment of 
hemorrhoids. It is perhaps to Allingham, Matthew, and Ricketts 
that this operation owes its great popularity. It is applicable to almost 
every variety. Many American surgeons, however, prefer the clamp 
and cautery method. Whitehead's method of total excision, or Earle's 
modification of the Whitehead operation, the Pratt or so-called American 
operation, are likewise popular. 

Preparation of the Patient. — In order to obtain the best results from 
any of the forms of operation, the patient should be as carefully prepared 
as for laparotomy. Thirty-six hours before the operation the bowels 
should be thoroughly emptied and the patient placed upon a very light 
diet. The evening before the operation, after the parts have been care- 
fully shaved to the anus and perineum, mercuric chlorid dressing should 
be applied and retained by a T-bandage. No purgative or injection 
should be given the night before the operation; on the contrary, the pa- 
tient should have a quiet, restful night. No enema should be given the 
morning of the operation, but after the patient is anesthetized the sphinc- 
ters should be dilated and the rectum thoroughly irrigated with a i : 3000 
mercuric chlorid solution and the external parts made surgically clean 
with soap and water, followed by the mercuric chlorid solution, and 
lastly, alcohol. The bladder should also be emptied before beginning 
any operation, and this should be done before cleansing the operative 
field. 

Postoperative Treatment of the Ligature Method. — Allingham 
attributes all the unfortunate results which follow this method to the 
faulty after-treatment. For the prevention of complications he lays 
down the following rules : He confines the bowels for four or five days, 

293 



294 POSTOPERATIVE TREATMENT. 

using opium or morphin freely for this purpose, and for the relief of pain. 
On the day following the operation the outside dressings are removed. 
The parts are dusted with iodoform or some such powder, and after 
this small pledgets of dry gauze will be necessary. To many patients a 
dressing moistened with a mild antiseptic solution, if applied hot, is 
more grateful. The bowels are moved, according to the necessity of 
the case, after four or five days. Whatever laxative is selected is given 
in sufficient dose to compel movement of the bowels, even against the 
patient's resistance, for at this time the sphincter will have regained its 
tonicity, and the fear of pain will cause the patient to hold the move- 
ment back as long as possible. The best laxative is one-half to one 
ounce of castor oil, administered in two to four drams of port wine. 

When the inclination for a movement begins to be felt, an injection 
of warm sweet-oil into the rectum will facilitate it, and prevent any fric- 
tion by the fecal mass upon the stumps and ligatures. In the major- 
ity of cases the patient may sit upon the commode for this purpose ; it 
makes the movement easier and causes less straining than when the bed- 
pan is used. As Allingham says, there are patients so anemic and 
debilitated that the recumbent posture is desirable, and in these the 
use of the bedpan for several days will be necessary. After the bowels 
have once moved, boric-acid solution should be injected into the rectum, 
and expelled again in order to wash away any fecal material which may 
have adhered to the raw surface. If there is any difficulty in obtaining 
a movement of the bowels, the finger should be introduced at once to 
ascertain if impaction has taken place; and if so, it should be broken up. 
Allingham advises the introduction of the finger into the bowel every 
day after the first week in order to avoid any contraction; he confines 
the patient to bed for one week or more, and does not allow him to walk 
about until the wounds are healed. 

After the bowels have moved for the first time, gentle traction should 
be made upon the ligatures daily in order to withdraw them when they 
have cut their way through. This should be very carefully done lest too 
much dragging should tear off a pedicle and thus bring about secondary 
hemorrhage. 

The time required for complete healing by the ligature method is 
from twenty-five to forty days. The period of confinement to bed is 
from five days to three weeks. 

After-treatment of the Clamp and Cautery Method. — There are 
two methods of treating the wounds following removal of the hemor- 



OPERATIONS UPON THE RECTUM, ETC. 295 

rhoids. One is the application of a soft, fluffy piece of gauze infiltrated 
with iodoform, xeroform, or orthoform to the external raw surfaces. 
This is covered with a good pad of gauze or absorbent cotton, and held 
in position by a T-bandage. If the sphincter is thoroughly relaxed 
and if there is no tendency to contract, this dressing is quite as satis- 
factory as any other. In many cases, however, it seems impossible 
to paralyze the sphincter muscles by stretching and in such cases it is 
customary to use a Pennington tube, which consists of a piece of me- 
dium-sized stiff rubber tubing about six inches long, attached to which 
is a sheath of very thin rubber. The tube or part to be inserted is wrap- 
ped with iodoform gauze until its size is sufficient to keep the sphincter 
well dilated, and the rubber sheathing is then folded over the gauze. 
The part of the tube surrounded by the gauze is then introduced about 
four inches into the rectum with the uncovered end of the tube protruding 
from the anus, orthoform or iodoform having been previously dusted 
freely upon the raw surfaces within and about the anus. The tube 
serves to allow the escape of any gas which may accumulate within the 
rectum, to control hemorrhage, and to maintain the dilatation of the 
sphincter. The rubber sheath prevents granulations from forming in 
the meshes of the gauze. The gauze is then packed around the lower 
end of the tube and a snug T-bandage applied, through which the end 
of the tube protrudes in order to prevent pressure upon the latter. A 
large safety-pin is fastened through the end of the tube in order to pre- 
vent its escape upward into the rectum, and thus the dressing is completed. 
As a rule, it is best not to use any plug or tampon in the rectum, but 
when there is much pain and contraction of the sphincter, the method 
of Pennington will prove of great service. The tube should be allowed 
to remain until the third or fourth day, or be allowed to come away 
with the first movement of the bowels. When the tube is used, the pa- 
tients generally have to be catheterized, and it maybe necessary to admin- 
ister one or two hypodermatics of morphin during the first twenty-four 
hours. It is customary to give a hypodermatic injection of morphin, 
h to \ grain, before the patient leaves the operating table. On the second 
night following the operation 20 to 30 minims of fluid extract of cascara 
or castor oil may be administered, and, as before directed, when the 
bowels feel like moving, warm sweet-oil should be injected into the rectum. 
After the bowels have moved and the rectum has been irrigated, a small 
piece of gauze infiltrated with some antiseptic powder should be applied 
to the anus two or three times a day, to keep it dry. If there is a tendency 



296 POSTOPERATIVE TREATMENT. 

to contraction or spasm of the sphincter, a full-sized rectal bougie should 
be introduced daily. 

The time for healing after this operation varies from two to four 
weeks, the average being twenty-one days. .Patients are allowed to 
get out of bed after the bowels have moved on the third or fourth day. 
They can generally walk about without any distress, but sitting may be 
uncomfortable. They are allowed to use a commode for the first move- 
ment of the bowels. There is often some hemorrhage after stools for 
the first week or ten days, but it is never alarming, and only comes from 
granulating surfaces. 

Crushing Method. — Some recent operators have used the angiotribe 
in earning out the crushing operation. Other instruments have been 
invented and used for this purpose, viz., Smith's and AUingham's being 
the most frequently used, but none are superior to the old Kelsey clamp. 
After having crushed the hemorrhoids, collodion should be applied. The 
parts will often heal as if they had been sutured. The cauterization 
of the stump before applying the collodion is a safeguard against hemor- 
rhage. 

Following the excision method, pain is usually very great for eight 
to ten hours. Alorphin is the best remedy to control it after all opera- 
tions, but if the patient is extremely nervous, large doses of sodium 
bromid will act more satisfactorily. The smarting pain which follows 
the movement of the bowels in either operation may be relieved by the 
application of pure iodoform or a 10 percent ichthyol ointment, or the 
insufflation of orthoform just before the stool. 

Strangury and dysuria very frequently occur after the ligature method. 
Hot applications over the pubis and allowing the patients to stand on 
their feet will frequently enable them to pass their urine voluntarily; 
but, these methods failing, catheterization should be performed under 
strict asepsis. 

Secondary Hemorrhage. — The danger of secondary hemorrhage 
is very much exaggerated. If severe, the rectum may be thoroughly 
packed with gauze. The introduction of astringents is unnecessary and 
injurious. 

Abscess and Fistula. — These conditions have been known to follow 
operations by ligature, by the clamp and cautery, and by the excision 
methods, and are usually the result of faulty drainage. The only 
treatment in these cases is to dilate the sphincter thoroughly and drain 
the abscess as soon as the swelling is discovered. After excision, the 



OPERATIONS UPON THE RECTUM, ETC. 297 

abscess may form in the stitch holes. As soon as they appear the sur- 
geon should remove the stitches and thus give exit to the pus. A sudden 
rigor with rise of temperature after forty-eight hours or more following 
the operation should excite suspicion and cause immediate examination 
of the parts. 

Stricture. — Stricture rarely follows except after the Whitehead oper- 
tion, and is usually due to cicatricial contraction. The rectum should 
be dilated daily with a moderate-sized bougie until the wound is entirely 
healed. 

Ulceration and Fissure. — Protracted ulceration or chronic fissure 
sometimes follows the Whitehead and ligature operations. The con- 
stitutional condition of the patient accounts for the majority of cases. 
Dilatation of the sphincter under anesthesia with applications of iodo- 
form or ichthyol ointment usually affords prompt relief. 

EXTIRPATION OF THE RECTUM. 

Preparation of the Patient. — In order to obtain the best result it is 
necessary to increase the patient's strength as much as possible by forced 
feeding for a time. The intestinal tract must be emptied of all hard and 
putrefying fecal masses, to establish so far as possible intestinal asepsis. 
Seven to ten days are usually required to properly prepare a patient for 
this operation. 

An absolute milk diet is not so satisfactory as a mixed diet composed 
of meat broth, milk, and small quantities of bread and refined cereals. 
The patient should be fed at frequent intervals, and given as much as 
he can digest. Daily saline laxatives should be given in sufficient quan- 
tity to produce two or three thin movements. The rectum should be 
irrigated by mild antiseptic solutions of mercuric chlorid, potassium 
permanganate, or, as recommended by Quenu, hydrogen dioxid. 

Numerous methods have been devised by various surgeons for extir- 
pation of the rectum by the perineal route, but on account of the vast 
areas of tissue laid open, and the unsatisfactory access to the rectum 
which they give, they have practically been rejected, though Cripps' 
and Allingham's methods remain popular, owing to the fact that the 
mortality from extirpation of the rectum by the perineal route is much 
lower than by any other method. After removal of the rectum by 
either of these methods the posterior and anterior portions of the peri- 
neal wound are packed with iodoform gauze and left open to insure 
drainage. The parts are covered with aseptic pads held in position by 



290 POSTOPERATIVE TREATMENT. 

well-fitting diaper or broad T-bandages. A large drainage-tube is 
passed well up into the rectum, its lower end extending outside of all the 
dressings in order to convey the discharge and gases beyond the opera- 
tive wound. 

Kraske's Operation, or the Sacral Method.— After all oozing is 
checked by hot compresses, the cavity of the sacrum is packed with a 
large mass of iodoform or sterilized gauze, the end of which protrudes 
from the lower angle of the wound. The skin-flap is sutured in its 
original position with silkworm-gut which passes deeply through the skin. 
The lateral portion of the wound is closed by similar sutures down the 
level of the sacrococcygeal articulation. Below this it is left open for 
a drainage. A large rubber drainage-tube is carried up through the gut 
beyond the line of intestinal sutures, and the whole is dressed with 
iodoform or sterilized gauze, held in position by adhesive straps and a 
firm T-bandage. The patient is placed in bed, lying upon his back 
or right side, and the head of the bed is elevated slightly in order to afford 
better drainage. There is always considerable oozing for the first twenty- 
four hours following the operation, during which time the outside dress- 
ings should be replaced several times by fresh ones. The inner packing 
or drainage should be left in position for seventy-two hours; after this 
it is removed, and either drainage-tubes or small gauze strips are intro- 
duced into the hollow of the sacrum. The patient is kept upon con- 
centrated liquid diet, and if a preliminary artificial anus has not been 
employed, his bowels should be confined by opium for the first ten days, 
after which they are moved by enemas of oil and glycerin. 

The Vaginal Method. — Extirpation of cancer of the rectum through 
the vagina or the removal of carcinoma of the lower loop of the sigmoid 
via the vagina has been popularized by Murphy, of Chicago. After 
extirpation, the peritoneum is closed with a continuous catgut suture 
and the vaginal wound is brought together with silkworm-gut sutures. 
A large drainage-tube is introduced through the anus above the point 
of anastomosis and sutured in position. The vagina and external parts 
are dressed with iodoform gauze. In order to facilitate better drainage, 
Tuttle recommends a semicircular incision between the anus and the 
coccyx, extending into the retrorectal space, and through this incision 
the sacral concavity is packed with iodoform gauze. The use of silk- 
worm-gut sutures in the intestinal wall necessitates their removal under 
anesthesia on the twelfth or fourteenth day. The use of a ten-day 
chromicized catgut serves every purpose and does not require removal. 



OPERATIONS UPON THE RECTUM, ETC. 299 

Combined Methods. — The combination of abdominal with other 
methods for extirpation of the rectum has been suggested from time to 
time. Abdomino-anal, abdominoperineal, abdomino-sacral, all have 
their advocates. Mayo's modification of MaunselPs method is a fine 
conception, and may prove later the ideal method. The after-treatment 
in all forms being practically the same, recovery is dependent upon 
proper drainage. 

When end-to-end approximation of the bowel has been employed, 
a large, firm, rubber drainage-tube should be passed through the anus 
and extend above the line of anastomosis is order to prevent any ten- 
sion upon these parts from the accumulation of gases or fecal material. 

Postoperative Complications. — Sepsis. — The chief complication 
which follows all forms of operation of extirpation is sepsis. According 
to Tuttle, 75 percent of the deaths occurring from extirpation for cancer 
of the rectum are caused by infection. Whether this is due to faulty 
technic, to the escape of fecal material during the operation, to ruptures 
of the sutures after the operation, or to the presence of bacilli in the peri- 
rectal tissues at the time of the operation, it is impossible to say. No 
technic has been devised which will positively secure asepsis in all opera- 
tions of this type. A certain amount of sepsis, therefore, is unavoidable. 
Every effort should be made to protect the peritoneum. 

Gangrene. — Gangrene is the next most serious postoperative com- 
plication. This may be the result of deficient blood-supply, too great 
tension of stitches, etc., or may result from infection. If from either 
of the first two causes, the condition will develop within the first twenty- 
four to thirty-six hours. If from the latter, the intestine may appear 
perfectly healthy for two or three days, and then entirely slough away, 
There is no possible way to avoid these complications except through 
the most rigid asepsis. The systematic employment of a prehminary 
colostomy simplifies the after-treatment and lessens mortality. 

Incontinence of feces is a very frequent complication following 
the sacral method of extirpation. To avoid this, Gersuny has proposed 
twisting the gut two or three times around before it is sutured in posi- 
tion. Willems carries the superior segment of the intestine through the 
fibers of the gluteus maximus muscles, thus constituting a sphincter ani. 

FISTULA IN ANO. 

Technic. — There are several methods of operating for fistula, and 
the after-treatment varies accordingly. The operation by radical ex- 



300 POSTOPERATIVE TREATMENT. 

cision as first recommended by Stephen Smith, of Bellevue Hospital, 
is now generally adopted. A medium-sized rectal tube wrapped with 
a small quantity of gauze and covered with rubber protective is intro- 
duced about three inches into the rectum and allowed to remain for 
several days, in order to facilitate the escape of gas which may come 
from the intestine above. 

The after-treatment of this method is as follows : The patient is 
confined absolutely to bed, the bowels are controlled by opiates for six 
or seven days, the patient being limited to albuminoid diet, but milk 
is excluded. At the end of six or seven days the bowels are moved by 
the injection of five ounces of warm water and one ounce of glycerin, 
in which is dissolved two ounces of inspissated oxgall. This proceeding 
may have to be repeated several times before an efficient evacuation is 
obtained, but Smith does not consider it advisable to attempt the use of 
any laxative or purgative until the lower bowels have been relieved of an 
accumulation of hardened fecal masses, such as are likely to follow the 
administration of opium and prolonged constipation. After these masses 
have been dissolved by the above method one may then administer some 
mild laxative and induce daily movements. 

Rest in bed is incumbent upon these patients for at least two weeks 
in order to secure firm and perfect healing of the part. The stitches are 
usually removed about the seventh day, but not before movement has 
been secured. 

When primary union fails, resort must be had to healing by granu- 
lation, the wound being treated similarly to other septic wounds. The 
large majority of failures which follow operations for fistula are due to 
one of two facts, either a specific fistula is mistaken for a simple one, 
or the opening into the rectum is not found and thus a part of the track 
remains. The method of after-treatment advocated by Grant, Tuttle, 
and others varies somewhat from the above, hence is given in full. 

Postoperative Treatment for Fistula in Ano (Method of Grant). 
— It may almost be said ihat the after-treatment of the case is of more 
importance than the operation. When all bleeding has been checked, 
the parts should be well dried, and a folded piece of lint, or better still, 
a strip of iodoform gauze, should then be lightly packed into the incision. 
A large pad of wool is applied over the part to maintain pressure, and to 
overcome any inclina 1 v*d to strain, and is fixed in place by a T-bandage. 
This outer dressing can be replaced later by a sanitary towel only. A 
suppository containing morphin may be employed. In forty-eight hours 



OPERATIONS UPON THE RECTUM, ETC. 301 

the first dressing should be removed, the part well washed, and redressed. 
The dressing consists of a folded piece of lint or of gauze firmly packed 
in the wound. It may be moistened with oil, or with iodoform or other 
ointment, or may be merely dusted with iodoform. The whole of the 
gap or gaps made by the operation must be well and carefully stuffed 
from the bottom. 

The part should be dressed night and morning and after each action 
of the bowels. Scrupulous cleanliness must be insisted upon. A hip- 
bath may be taken daily after the action of the bowels. The bowels 
should at first be kept confined, but should be opened by means of a 
dose of castor oil on the third or fourth day. It must be seen that they 
act regularly after this. The discharge will be free for about the first 
ten days. The dressing may need to be changed from time to time, and 
the lint may be soaked with zinc sulfate lotion, with a silver nitrate solu- 
tion, with the compound tincture of benzoin, with weak iodin, or with 
such other drug as the surgeon employs in like cases. 

The parts may be overdressed and the skin around be kept in a con- 
dition of irritable inflammation. Every care must be taken that the skin 
does not heal over prematurely, and a constant watch must be kept for 
burrowing sinuses and for undermining of the skin. Pockets for pus 
soon form, and good drainage should be maintained throughout. 

The diet should be simple, but not meager. Every means should be 
taken to improve the general health. 

The operation will probably require, in an ordinary case, confine- 
ment in bed for some fourteen days, followed by another week or so in 
the house. In a complex case, with many deep sinuses, the after-treat- 
ment may extend over many months. Rest is all-important, and 
the healing process is very distinctly retarded by too early movement. 
Change of air will often do more for an indolent sinus than will the 
most elaborate dressing. Some loss of power over the sphincter will 
be noticed for a little while. It is generally regained within three weeks. 
A permanent weakening of the anus may result, but it is very uncommon. 

The treatment of fistula by the elastic ligature was at one time 
extensively employed. It is attended by no hemorrhage, and was 
recommended for cases of deeply extendng fistula. The ligature is 
made of a solid cylinder rubber cord, one-tenth of an inch in diameter. 
One end of the loop is introduced along the sinus by means of a special 
director, while the other end hangs in the rectum. A pewter ring is 
then threaded over the two ends, and as the ligature is drawn tight, 



302 POSTOPERATIVE TREATMENT. 

the ring is made to clamp the two cords by compressing it with necrosis 
forceps. The ligature is allowed to cut its own way out. This it will 
effect, on an average, in six days. There is little to recommend the 
measure, which is attended by no little pain. In individuals suffering 
from hemophilia, I imagine the risks of bleeding would be as great after 
the use of the ligature as of the knife. It has not been shown that the 
after-treatment is shortened by this method. 

URETHROTOMY. 

General Remarks. — After operations upon the urethra the former 
custom of allowing the catheter to remain has been abolished largely, 
for the reason that it is not only uncomfortable to the patient, but fre- 
quently produces urethritis; nor is it essential that a drainage-tube 
should be introduced into the perineal opening. The best plan is to 
allow the wound to remain open and have the urethra irrigated several 
times a day with warm Thiersch's solution and have the perineal wound 
kept thoroughly clean by the same means. By the use of proper anti- 
septics the urine is soon made aseptic, which tends to keep the part free 
from infection. A full-sized sound should be passed even* three or four 
days until the urethra is healed. A pad is usually placed between the 
knees and the limbs kept together by means of broad bandages to prevent 
the careless spreading of the thighs. Should an abscess or swelling 
form in the region of the perineum, which is usually accompanied with 
severe pain and symptoms of acute suppuration, it must be evacuated 
through the perineal incision, being careful not to injure either the rec- 
tum or the urethra, and after thorough evacuation the cavity should 
be tamponed with iodoform gauze. The opening in all cases should be 
made large enough to insure permanent drainage. 

Some surgeons prefer to open prostatic abscesses into the rectum to 
avoid infection. If, however, the perineal incision just described has 
been made, and if the patient has received proper preliminary treat- 
ment, consisting of a thorough laxative and flushing of the bowels 
previous to performing the operation, the perineal method is prefera- 
ble. The administration of saline laxatives daily and thorough flushing 
after the evacuation of the bowels tend to render the patient more com- 
fortable and the results more satisfactory. The patient should be 
placed in bed on his back, with some absorbent material imder his 
buttocks to catch the urine; his thighs should also be protected from 



OPERATIONS UPON THE RECTUM, ETC. 



3°3 



the irritation caused by the urine by means of benzoated zinc oxid 
ointment and by frequent sponging with alcohol or boric-acid solution. 

Immediate suture of the perineal wound has been tried, but experience 
shows that it is attended with great risk; the deep portions of the wound, 
which have been more or less bruised by instruments, may slough 
slightly or heal more slowly than the skin-surfaces, and in this event 
extravasation of urine is likely to occur; whereas if the wound be allowed 
to close slowly, healing begins at the bottom. After perineal lithotomy 




Fig. 86. — Section of Hypertrophted Prostate. — (Duplay and Reclus.) 
U, Urethra; E, ejaculatory ducts; T, fibrous tuberculae; C, prostatic nodules; Z, fibro- 
muscular capsule; V, periprostatic veins; F, fibroglandular tissues; S, section of seminal 
vesicles. 



the patient should remain in bed for from two to four weeks, except 
in cases of children, who recover very rapidly after the operation. 

Internal Urethrotomy. — Should hemorrhage occur after internal 
urethrotomy, an ice-bag should be applied to the perineum with ele- 
vation of the pelvis, or a full-sized catheter (flexible, if possible) may be 
passed and left in, while a firm pad of wool is fixed against the perineum 
by a T-bandage. The catheter should be kept clear, and the urine 
should run continuously through it and an attached rubber tube. An 
opiate should be given if there is pain or restlessness. 

In order to keep the cut surfaces from growing together, a sound 
should be passed every day for the first week, and subsequently every 
second or third day. Later, the passage of the sound need take place 
only once a month, but there is always danger of contraction unless a 
sound is passed at intervals. 



304 POSTOPERATIVE TREATMENT. 

To avoid rigors after internal urethrotomy, the patient should be 
kept thoroughly warm in bed, should not try to pass urine for a few hours, 
and should drink freely warm water or weak tea. Should a rigor occur, 
it should be met by the immediate administration of 10 grains of quinin 
in hot brandy and water. 

External Urethrotomy. — When clamp forceps have been used and 
left in situ to control hemorrhage, they may be removed safely in thirty- 
six hours. General oozing is then controlled by firm pressure with iodo- 
form gauze packed into the wound and around the drainage-tube or 
catheter. 

The most important indication after urethrotomy is not only thorough 
drainage from the bladder, but every effort should be made to prevent 
the urine from coming in contact with the freshly made wound until 
septic absorption is guarded against by the formation of granulations. 
This is ordinarily accomplished by carrying a large rubber drainage- 
tube or No. 30 French catheter through the wound into the bladder 
and stitched to the wound to prevent its being forced out. Iodoform 
gauze is then carefully packed around the catheter. The end of the 
drainage-tube or catheter is then attached to a large tube which drains 
into a urinal, or if desired, a vessel on the floor. 

The gauze packing should be removed from around the tube in forty- 
eight hours and the wound irrigated with hydrogen dioxid and carefully 
repacked. The bladder should also be irrigated thoroughly at least 
once a day with Thiersch's fluid. About the seventh to the tenth day 
after the operation, when granulations are formed, the drainage-tube 
should be removed from the wound and a curved sound passed into the 
bladder. The sound is passed every second or third day into the bladder 
until the perineal wound is healed, when the patient may be discharged. 
Should a stricture also exist in the anterior part of the urethra, it may 
be divided by internal urethrotomy, after which a large straight sound 
should be passed through the meatus and anterior urethra down to the 
drainage-tube or posterior perineal opening. This should be repeated 
every alternate day until the drainage-tube has been removed from the 
wound and bladder. 

From the first the patient is placed upon a light diet and directed to 
drink freely of water and milk to dilute the urine. Five-grain doses 
of urotropin thrice daily may also be given as an antiseptic. After the 
first forty-eight hours the patient may be allowed to assume a sitting 
position in bed, and a week after the operation may be permitted to sit 



OPERATIONS I PON THE RECTUM, ETC. 305 

in a chair. On closure of the perineal opening the patient usually has 
the ability to retain the urine in a normal manner. Stricture is almost 
certain to take place unless the patient passes a sound at intervals. He 
should, therefore, be taught how to do this without injury, and the fact 
of its neglect must be earnestly impressed upon him so that he may not 
neglect the precaution. 

Postoperative Infiltration or Extravasation of Urine. — Postopera- 
tive infiltration or extravasation of urine may occur as a result of too 
rapid healing and failure to keep the urethra well dilated. Obstruction 
of the drainage-tube by means of blood-clot or faulty dressings, and 
attempts of the patient himself to void urine by straining and pressure, 
may cause a rupture of the thin walls of the urethra, and the urine may 
thus escape into the cellular tissues. It occasionally happens after 
operations for stricture; premature closing of the wound or attempts 
at the introduction of a catheter or sound may result in a false opening 
in the posterior urethra, and extravasation follow. 

When, as is frequently the case, the extravasation occurs in front of 
the subpubic ligament, the urine burrows through the cellular tissue 
of the scrotum and penis, and extends upward toward the hypogastrium. 
Abscess rapidly forms, the tissues become gangrenous and slough, and 
spontaneous evacuation of the pus and urine occurs, with considerable 
destruction of tissue, leaving urinary fistulas. The septic condition is 
always very pronounced, and such patients usually die unless an opera- 
tion is performed promptly. 

When the rupture of the urethra takes place posterior to the subpubic 
ligament, the burrowing of urine takes place in a different direction. In 
this case the urine cannot make its way forward through the cellular 
tissue of the penis, but it burrows under the deep layer of the perineal 
fascia and accumulates in the prevesical space, forming a swelling above 
the symphysis. From this point it extends, and inflammatory swelling 
and suppuration of the connective tissue within the abdomen occur and 
the patient dies of pyemia. 

Treatment. — Urinary extravasation demands immediate operation 
in order to save the patient's life and prevent extensive sloughing and 
loss of tissue. An external incision should be made and the bladder 
drained through a catheter in order to prevent further escape of urine into 
the tissues. The collections of pus and urine in the tissues, no matter 
where located, should be opened up, drained freely, and packed with 
gauze. If , the prostatic urethra was ruptured behind the subpubic 



306 POSTOPERATIVE TREATMENT. 

ligament and extravasation has taken place into the prevesical space, 
the pus and urine should be evacuated by means of a suprapubic 
cystotomy. 

AFTER-TREATMENT IN REMOVAL OF THE PROSTATE 
AND OF THE PROSTATIC URETHRA. 

Moynihan's Method. — Moynihan gives the following directions: 
"The catheter is passed after the removal of the organ, and the bladder 
freely flushed with hot, sterile saline solution or a hot i percent solution 
of carbolic acid. When the fluid returns almost clear, a large rubber 
tube is passed into the bladder, and a couple of stitches introduced into 
the wound. There are often severe paroxysms of pain for a few hours 
after the operation, but they are relieved by morphin. At the end of 
forty- eight hours the tube is removed from the bladder, and the patient 
allowed to sit up with a bed- rest. On the fourth day and each succeed- 
ing day a catheter is passed and the bladder freely washed with dilute 
carbolic-acid lotion. On the seventh day the catheter is tied in and a 
drag placed on the suprapubic wound, which is removed every morning 
and the bladder again flushed. The catheter is not removed for five 
or six days; a new one is then introduced. The patient is allowed to 
get up and sit in a chair at the end of the first week if he is a feeble old 
man. The urine ceases to come through the wound about the end of 
the third week, and at the end of the fourth or occasionally not until the 
end of the fifth, the patient is passing urine spontaneously at natural 
intervals, and the wound is entirely closed. " If there has been a cystitis, 
he orders urotropin or helmitol, 10- to 15-grain doses three or four times 
daily. 

Suprapubic Prostatectomy. — No attempt is made to sew up the 
bladder wound, the two stitches inserted into each edge being secured 
to the skin. A large soft-rubber tube is then inserted and fixed by a 
stitch; a large absorbent dressing is now applied over the pubes, and 
retained by a many-tailed bandage. The whole of the urine escapes 
through the wound for two or three weeks, and very frequent change 
of dressings and constant attention to cleanliness are required on the 
part of the nurse. 

The bladder should be gently washed out every day with a warm 
solution. The tube and stitches may be removed in two or three days' 
time. About two or three weeks after the operation the urine begins to 
pass through the urethra, and this should be favored by keeping the 



OPERATIONS UPON THE RECTUM, ETC. 307 

patient in the sitting posture and getting him out of bed as soon as pos- 
sible. 

If the entire obstruction has been removed, the bladder will regain 
control in from a month to six weeks after the operation. The condition 
of " vesical atony" which was supposed to be present in many cases of 
prostatic enlargement appears to have no real existence. (Freyer.) 

Vital Points in the Technic of Suprapubic Prostatectomy. 
(E. Hurry Fenwick, London, Eng.) — Our suprapublic technic for 
prostatic enucleation is faulty in three directions. 1. The destruction 
oj the vesical or orificial ring. 2. The wholesale destruction of the 
prostatic urethra with its afferent seminal ducts. 3. The rough man- 
ipulation of the membranous urethra. No matter how the operation 
of removal is carried out, whether above or below, the original vesical 
orifice must be left intact and covered with its own mucous membrane. 
Neglect of this simple axiom will inevitably leave the patient with a 
narrowed or warped vesical orifice due to cicatricial contraction with 
its attendant miseries and perhaps dangerous sequels on account of the 
destruction of the ejaculatory ducts. Very many patients immediately 
and absolutely refuse the suprapubic operation because they cannot be 
promised that they will retain sexual power. I am convinced of the 
tonic value of the male sexual function in maintaining arterial health 
and even longevity, therefore, ruthless destruction of the secretion of 
these glands will not only bring the operation into disrepute, but will 
greatly minimize the excellent future results obtained by the procedure. 
The membranous urethra is easily damaged by the separation of the an- 
terior surface of the prostate from the face of the triangular ligament. 
It is astonishing how easily the mucous membrane is bruised and its 
muscles lacerated. As this is the future reinforcing sphincter of the 
bladder after prostatic enucleation, it should be very gently and cau- 
tiously handled. 

Perineal Prostatectomy. — The open-wound method is preferable 
when the perineal operation is performed, but in severely infected 
bladder cases Ochsner recommends the introduction of two drainage- 
tubes well up to the fundus of the bladder, so that irrigation may be 
accomplished by injecting fluid through one tube and permitting it to 
escape through the other after the operation. When there has been 
considerable hemorrhage from the capsule and hemostatic forceps have 
been applied and allowed to remain and protrude through the wound 
they can be safely removed after twelve to twenty-four hours, or if there 



308 POSTOPERATIVE TREATMENT. 

has been considerable oozing, the space around the drainage-tubes may 
be tamponed with a sufficient amount of iodoform gauze, and in this 
case the gauze should be removed on the third or fourth day. In all 
cases the bladder should be irrigated with normal salt or boric- acid 
solution, from one to six times a day, according to the condition of the 
bladder. After the sixth to the tenth day the rubber drainage-tube 
should be removed. At this time the patient will ordinarily have no 
difficulty in evacuating the bladder normally, but in case the flow of 
urine is not normal, a soft-rubber catheter should be introduced through 
the urethra into the bladder for a few days. The patient should be 
encouraged to sit up the second or third day after the operation, for the 
reason that elderly men do not bear confinement well. 

Perineal Prostatectomy (A. H. Ferguson). — This method does 
not necessarily remove the entire prostatic urethra as is done 
by the suprapubic route. It is possible to remove the entire gland 
in one piece without injury to the bladder, ejaculatory ducts, or 
prostatic urethra in suitable cases. Large forceps materially aid in 
seizing and holding large masses of tissue. When the prostate is a 
bar of tissue at the neck of the bladder, or is a stricture at the internal 
vesical meatus, with or without a protrusion, these conditions are usually 
noticed early in the operation and treated by dilation or removal by 
the cutting forceps. 

Importance of Drainage (Ferguson). — Nearly all my patients were 
drained through the perineum. I am convinced that the technic is im- 
proved and convalescence is shortened by drainage through the penis 
by an ordinary retention catheter, No. 23 American. (Fig. 87.) 

The membranous and prostatic portion of the urethra are closed by a 
few stitches of No. 1 chromic catgut, and the deep wound is drained by 
gauze alone, at the most dependent part, and all the structures of the 
perineum are coapted by an interrupted suture of silkworm-gut. The 
gauze drainage in the perineum is removed on the third day and replaced ; 
in a couple of days this gauze is withdrawn, but the retention catheter 
is left in the bladder and external urinary tract for a week. During 
this time should temperature develop or vesical tenesmus arise, it is 
well to wash out the bladder three or four times a day with a mild anti- 
septic solution. I have obtained perfect results by the above technic. 

After the catheter is removed, retention of urine is likely to ensue 
from spasmodic contraction of the neck of the bladder. This is rather 
a good sign, for it indicates that the sphincter of that viscus has not 



OPERATIONS UPON THE RECTUM, ETC. 



3°9 



been injured and the retention is easily rectified by the use of the catheter. 
I have seen men become greatly discouraged and even melancholic after 
prostatectomy, especially when temporary control of the urine is partly 
or wholly absent. But just as soon as the bladder again performs its 




Fig. 87. — Jacob's Retention Tube or Catheter. 

a, Shows the bulb-like end which it assumes when in place; b, shows the end stretched 
over a probe c in order to reduce its size during introduction. This tube is used in 
draining cavities like the urinary bladder, gallbladder, etc. 



function properly, they become bright, cheerful and hopeful. After 
prostatectomy the patient should be kept under supervision for about 
three months, because repair is not complete until about that time. 
Should the patient not be bougied occasionally, at least once a week 
while repair is going on, stricture at the neck of the bladder or at the 



310 POSTOPERATIVE TREATMENT. 

junction of the membranous and prostatic urethra is likely to occur. I 
have found it necesary to perform a secondary perineal section in two 
cases for stricture following prostatectomy ; one at the neck of the bladder 
and the other at the junction of the membranous and prostatic urethra. 
For the latter I blame the perineal drainage alone. 

It is remarkable that atony of the bladder subsides completely in the vast 
majority of cases, but some bladders never become capable of emptying 
themselves after prostatectomy without considerable delay and difficulty. 
There is also a tendency to cystitis. 

The Scrotum. — For the removal of cancerous or tuberculous tumors 
all superfluous scrotal tissues should be removed, and after removal 
of the testes all bleeding points clamped and tied. Oozing into the 
scrotum gives rise to much trouble on account of the laxity of the tissues, 
and the long time it requires for clot to become absorbed, and the lia- 
bility to infection. As scrotal tissue usually swells rapidly, care should 
be taken that the stitches be not too tightly drawn. Drainage is always 
essential in scrotal operations, the postoperative treatment being the 
same as that of other wounds, drainage being necessary for at least forty- 
eight hours. 

In patients advanced in years the postoperative shock is sometimes 
considerable, hence the operation should be performed with as little trau- 
matism as possible, and frequently an inguinal incision only should be 
made. 

Epididymitis sometimes occurs as a complication after an operation 
upon the scrotum. It is usually manifested by severe pain, a chill, 
followed by fever, rapid enlargement, with edema of the scrotum. 

Treatment. — Rest in bed; saline purge; wrap testicles in lead- water 
and laudanum and elevate with handkerchief bandage; hot compresses 
and hot- water bag to inguinal region; properly fitted suspensory bandage 
strapped in recumbent position over thick sheet of absorbent cotton or 
wool; in severe cases puncture vaginal tunic and cellular tissue at back 
of scrotum (introduce knife not deeper than one-half inch) and then 
apply suspensory bandage or elevate testes with handkerchief; keep 
testicle constantly wet with lead- water and laudanum on lint or a 10 
percent solution of iodoform in glycerin; morphin hypodermatically 
if pain is severe; later incise if pus is suspected, and drain with iodoform 
gauze; strapping or suspensory bandage after acute symptoms subside, 
followed later by application of ointment of iodoform i part to 7 parts of 
belladonna ointment. 



OPERATIONS UPON THE RECTUM, ETC. 311 

CASTRATION. 

General Considerations. — The skin incision should be carried to 
the bottom of the scrotum, in order to secure good drainage. It may, 
however, be noted that the higher up the incision is placed, the more 
easy it is to avoid septic contamination, and that unless the testis is of 
great size, it is possible to remove it through a moderate incision made 
near the external ring. The bottom of the scrotum may then be drained 
for twenty-four hours through a separate puncture. 

When the skin is implicated by the disease, the incisions should extend 
beyond the diseased area and involve sound skin only. It is not necessary 
to remove redundant skin, unless it be excessive in amount and much 
atropied. If any sinuses be left behind, as after the removal of a tuber- 
culous testis, they should be most carefully scraped with a Volkmann's 
spoon. The cord should be secured about one inch from the testis. 
If it be involved, it should be divided higher up. It can seldom be 
necessary 7 to open up the whole inguinal canal to secure the cord, as 
advised by some. If the disease has extended to the external ring, the 
expediency of any operation may be questioned. Before the cord is 
secured and divided the anesthetic may be discontinued for awhile, 
as the section is sometimes attended by a very marked and sometimes 
alarming sinking of the pulse. 

It must be remembered that the cord is very much dragged down by a 
large growth; and if secured very high up, the stump, after section, may 
be withdrawn beyond easy reach when the heavy tumor is removed. 

The chief bleeding to be feared after castration is venous rather than 
arterial. It is unwise to include the entire cord in one ligature; the 
vessels are not w r ell secured by this means. The loop of thread may slip 
off when the clamp is removed. A substantial ligature (if single) must 
be employed, and it may excite suppuration until it is discharged. 
Secondary hemorrhage may follow the loosening of the single ligature. 
Neuralgia of the cord may also attend the procedure. 

The same objections apply, but in a less degree, to the practice of 
transfixing the cord with a needle and ligating it in two segments. 

Sometimes a tuberculous or syphilitic testis has to be operated on in 
wmich suppuration has already supervened, and the parts are thoroughly 
septic. In such a case, although all possible precautions are taken at 
the time of the operation, the surgeon can hardly hope for primary union 
and free provision for drainage should be made. In nearly all cases 



312 POSTOPERATIVE TREATMENT. 

of tuberculous orchitis the vas is invaded with tubercle bacilli along its 
whole course by the time the patient consents to operation. Owing to 
this fact, a troublesome complication after simple castration is the devel- 
opment of a secondary lump or abscess around the severed end of the 
vas. This may occur weeks or months after the wound has apparently 
healed. Partly to avoid this, and also to make a complete clearance 
of all the tuberculous disease, the plan has been carried out of removing 
the lower end of the vas and the corresponding vesicula seminalis by 
the perineal route, while the other end is pulled away with the testis 
through an incision prolonged into the inguinal canal. Reverdin and 
other surgeons have proved that it is thus possible to remove the whole 
length of the vas, but the proceeding is one of considerable difficulty 
and of very doubtful value. The. perineal part of the operation, con- 
ducted through a curved incision made in front of the rectum and across 
the median raphe, is similar to and even more difficult than perineal 
prostatectomy. The vas and vesicula have to be reached at the bottom 
of a deep and narrow wound, there is apt to be most troublesome venous 
hemorrhage, and there is some risk of damaging the bladder wall (to 
which the vesicula is closely bound by the rectovesical fascia) or the ureter. 
Finally, the wound is placed very badly for aseptic purposes. To drag 
the greater part of the vas deferens out through the inguinal canal is 
also a rough and hazardous procedure. When it is added that tubercu- 
lous disease of the vesical neck or prostate is often present with disease 
of the vas deferens, and that spontaneous recovery from both is not 
infrequent, the arguments in favor of combined perineal and inguinal 
operations are seen to be but feeble. The operation was described in 
the "Gazette des Hopitaux," October 15, 1898, and also in the "Bull, 
de la Soc. Anatomique," 1898, p. 603. 

Erasion of the Tuberculous Epididymis. — In removing the whole 
organ the surgeon is often taking much more than is actually diseased 
for in the majority of cases the testis proper will be found to be free from 
tubercle. It is the epididymis and the vas which are involved with so- 
called "crude tubercle," while occasionally the testis becomes affected 
with miliary deposit. Hence a very thorough erasion and excision of all 
the tuberculous foci will often suffice, and the testis itself may be safely 
retained. We have known cases in which the whole epididymis and . 
several inches of diseased vas deferens were excised, the testis remaining 
for years of normal consistence and size. Some importance is to be 
attached to the retention of the "internal secretion" of the testis. 



OPERATIONS UPON THE RECTUM, ETC. 



313 



The crasion must be effected through a free incision, the testis being 
turned out and the tunica vaginalis being laid open. Every particle 
of tuberculous tissue should be cut or scraped away, and if the vas is 
diseased, it also should be dealt with. Care should be taken not to 
damage the main vessels of the cord, and if this be avoided, the hemor- 
rhage will only be slight. Finally, the testis and its vessels are replaced 
in the scrotum, and a small drainage-tube left in the wound for a few 
days. 

After-treatment. — The scrotum is well slung up by a light roll of loose 
gauze applied as a suspender. This gauze clings to the skin better than 
any other dressing. The wound may be then dressed with a sponge 



m*m*m 



wm-k 



mm 




Fig. 88. — Tuberculous Disease of the 
Epididymis with Miliary Deposits 
in the Testes. — (Moullin.) 




Fig. 89. — Hernia of the Testicles 
following Tuberculous Disease; 
Removed from Infant, JEt. Two. — 
(Moullin.) 



dusted with iodoform, or with a pad of Tillmann's dressing packed all 
around with gauze, and secured by means of a T-bandage or a spica. If 
this be properly applied, the sponge or pad exercises firm but gentle 
pressure upon the wound. The drainage-tube should be removed in 
twenty-four hours, and the dry dressing continued. In the first twenty- 
four hours after the operation retention of urine may exist. The scro- 
tum is easily inflamed by the use of irritant lotions — e. g., strong car- 
bolic solutions. 

Should suppuration occur, constant care must be taken to prevent 
bagging. The sutures are removed on the fifth to the seventh day. 
The patient will probably complain of the hard, tender swelling which 
usually appears at the external ring, and which is due to inflammatory 



3i4 



POSTOPERATIVE TREATMENT. 



changes in the stump of the cord. As the wound heals, the cicatrix 
becomes depressed, from the obliteration of the scrotal pouch. If 
primary union be not obtained, the edges of the wound may need to be 
retained in contact by strapping. 

Comment. — In some cases the descent of a hernia after castration 
has forced open the wound, the rupture having been previously kept 
up by the enlarged testicle. During the operation, moreover, hernial 
sacs have been inadvertently opened up. If a scrotal hernia exists, 
the rupture should be reduced, the sac excised, and its neck ligated, the 
same as for the radical cure of hernia. 

HYDROCELE. 



Open Method of Treatment. — An incision through the skin and 
into the tunia vaginalis, preferably suprascrotal or in the lower inguinal 
region, sufficiently large to permit the introduction of drainage, is made, 

and before the escape of all the fluid 
,;vW.:^^,,.. ij the cavity is packed gently with iodo- 

form gauze as high up toward the 
external ring as possible. A small 
gauze drain is also introduced down- 
ward into the scrotum, over which the 
ordinary dressings are applied and held 
in place by a suspensory bandage. The 
gauze drainage after the fourth day is 
gradually removed and the wound 
allowed to heal by granulation in from 
seven to ten days. 

CIRCUMCISION. 




Fig. 90. — Open Incision and Su- 
ture of Sac. — (Moullin, after v. 
Valkmann.) 



After-treatment (Cheyne).— When 
the separation of the prepuce from 
the glans does not give rise to a raw 
surface, after using fine catgut sutures, the simplest plan is to dry the 
line of incision, lay a little salicylic wool over it, and fix it in position 
with flexible collodion, which dries quickly and may be left for a week. 
The patient should then be placed in a sitz-bath about a quarter of an 
hour before the surgeon's visit. The dressings may then be peeled off 
without causing much pain. Any raw surface remaining may have 



OPERATIONS UPON THE RECTUM, ETC. 315 

a small fresh dressing applied to it. However, when the surface of 
the glans is left raw, a better method is to wind a strip of wet boric- 
acid lint around the line of union, while outside of this a large layer of 
wet boric-acid lint is applied, so as to cover the whole penis and 
scrotum, and this is covered with oiled silk or jaconet and kept in posi- 
tion by a T-bandage. The outer dressing is changed repeatedly for 
several days until the parts are healed. After the first three days the 
inner layer of boric-acid lint may be soaked off and a narrow strip 
saturated with boric-acid ointment may be applied in its place. If 
silk or other nonabsorbable sutures are used, they may be removed on 
the fifth to the seventh day. 

Bransford Lewis' method of after-treatment, which we have employed 
several times with success, is as follows : After cleansing and drying the 
penis, it is encircled loosely with a piece of cotton inclosed in a layer of 
gauze. This is then thoroughly saturated with compound tincture of 
benzoin applied with a medicine-dropper. On drying, this dressing 
becomes moderately firm, forming, as it were, an antiseptic splint. A 
Teufel support bandage is put on, which holds the dressings in good 
position. The dressing is renewed after three to five days. In eight 
days the parts are usually securely healed and all dressings are removed, 
except possibly some mild dry dusting-powder. With this form of 
dressing in adults it is not necessary for the patients to suspend work or 
lay up after the operation, but they are directed to continue in their 
usual employment. 



CHAPTER XIV. 
MISCELLANEOUS OPERATIONS. 



CHAPTER XIV. 
MISCELLANEOUS OPERATIONS. 

LIGATION OF ARTERIES. 

Operations for ligation of arteries are usually performed under strict 
asepsis, and under such circumstances the after-treatment of the wound 
presents nothing different from ordinary aseptic wound treatment. 
In case of the main artery of an extremity, the limb should be kept 
absolutely at rest and be a little raised. The arm should lie outstretched 
upon a pillow, the lower limb raised upon an inclined plane. The whole 
extremity is enveloped in cotton wool and is kept warm by hot bottles. 
In case vessels the size of the iliacs, the subclavian, or the common 
femoral are ligated, absolute rest should be enforced for a period of 
not less than twenty-one days. 

The time involved in the after-treatment of cases in which smaller 
vessels have been ligated may be regulated in proportion. The period 
of compulsory rest should be longer in old subjects than in the young, 
and in cases in which the lower limb is concerned than in the upper. 

ABSCESSES. 

General Considerations. — When pus collects in any cavity or new 
formation in the body, in a recognized quantity, such collection is 
called an abscess. If it be well denned, held in position by a limited 
wall or membrane, it is a "circumscribed abscess," and when infil- 
trated in the tissues it is called "diffuse." A rapid recent collection 
of pus is called an acute abscess, a slow-forming or chronic collection, 
with little or no inflammatory reaction, is called a cold abscess. (Wyeth.) 

The distinct characteristics of the various sorts of abscesses depend 
upon the character of the pus and the location or character of tissue 
in which they are formed. The amount of pain in purulent inflamma- 
tion differs greatly: in some cases it is intense, in others entirely absent, 
depending largely upon the tissues or amount of nerves in the part 
affected. The amount of pain also depends upon the rapidity with 
which the abscess forms. If the pus accumulates rapidly, the pain 

3*9 



320 POSTOPERATIVE TREATMENT. 

will be more intense; if slowly, the tissues become accustomed to the 
distention. 

General impairment of the circulation, general anemia, or other 
systemic conditions — such, for instance, as diabetes — increase the 
tendency to suppuration and markedly interfere with recover}*. 

General Treatment. — When acute abscess exists, whether cir- 
cumscribed or diffuse, it should be freely evacuated. The point of 
greatest importance is to have the opening or openings in such position 
that drainage from the most dependent portion of the cavity is accom- 
plished. Thorough drainage is indispensable. So soon as the abscess 
is opened the cavity should be thoroughly but gently irrigated with 
a solution of i : 3000 mercuric chlorid, lysol 1 percent, or a saturated 
solution of boric acid, after which rubber or gauze drainage should be 
inserted, the treatment thereafter being similar to that of open treat- 
ment of septic wounds. It should be remembered, however, that gauze 
drains pus but poorly, and in many instances a rubber tube for drainage 
is better. 

Tuberculous or cold abscess, in case there is no deformity or marked 
discomfort to the patient, may be left unopened. When for any reason 
it is considered best to incise a tuberculous abscess, incision should be 
performed under the most strict asepsis, and the cavity, partly filled with 
an emulsion of iodoform and glycerin, should then be closed and her- 
metically sealed. 

Some surgeons prefer to evacuate all tuberculous abscesses with an 
aspirator instead of incision. When this is carefully done to the exclu- 
sion of air, particularly in small abscesses, and with the thorough 
cleansing of the abscess, constitutional disturbance is rare. Should, 
however, inflammation and suppuration follow, free incision should 
be practised and thorough drainage established. 

Pulmonary Abscess. — Incision axd Drainage. — Where the 
visceral and parietal layers of the pleura are not adherent, the sim- 
plest way of securing approximation of the two layers is to unite them 
by a series of local stitches, the same as is employed in ordinary needle 
work. Fine catgut sutures should be used, and these should be inserted 
before the pleura is opened. As a rule, however, the lung is consolidated 
in case of pulmonary abscess and the tissues so adherent that they do 
not fall away from the fixed wall to any material extent. After the 
evacuation of the pus the cavity should be swabbed out with a solution 
of zinc chlorid (40 grains to the ounce). A large-sized drainage-tube 



MlSri'l I.ANKOl S Ol>l RATIONS. T> 21 

should then be introduced into the cavity, and packed fairly firmly 
around with iodoform gauze. The tube should be large enough to 
exert sufficient pressure upon the lung tissue surrounding it to check 
oozing. The wound is left open and a large dressing applied. The 
tube should be left in position three or four days, until its track is well 
established; it should then be removed, washed, and replaced, or a 
gauze drainage substituted therefor. The abscess cavity should not 
be irrigated, but insufflation of iodoform or boric-acid powder may be 
practised at each dressing. The tube or drainage should be retained 
until the discharge is mucoid in character and all expectoration has 
ceased. It is important always to secure the drainage-tube in position 
by means of a safety-pin, lest it slip into the pleural cavity and neces- 
sitate an additional operation. Neglect that would lead to such disastrous 
results is little short of criminal, but instances in which this has occurred 
are too plentiful. 

Retrorectal Abscess. — A semicircular incision between the anus 
and coccyx is the best in these cases. After thorough evacuation the 
pus-cavity should be washed out with hydrogen dioxid, followed by 
i : 2000 mercuric chlorid solution. The sphincter should always be 
stretched after the abscess cavity is evacuated and the stools kept regular 
but not loose. As to drainage for these cases, a double rubber tube 
is preferable to gauze. Frequent irrigation with antiseptic solution 
is very important. If the abscess wound exhibits a sluggish tendency 
and the abscess does not heal as rapidly as the general condition would 
'indicate, the tube should be removed and the cavity swabbed out with 
95 percent carbolic acid or pure ichthyol. If the latter is used, the 
better plan is to saturate a narrow strip of gauze with the drug, which 
is then introduced into the cavity and left for two or three hours. It 
should then be removed and the drainage-tubes introduced. Patients 
may be allowed to walk or stand upon their feet, but sitting should 
not be allowed until the abscess has practically healed, as this posture 
interferes materially with the circulation and drainage of the parts. 
Tonics, good nourishing diet, and such medication as seems indicated 
should be employed. 

Psoas Abscess. — In the method of Sir Frederick Treves a tube 
of a Leiter's irrigator is introduced into the center of the abscess, and, 
the cistern being placed at a height of four to six feet above the level 
of the table, a large stream of the mercurial solution or warm water 
is allowed to run through the abscess. During this process of irriga- 



322 POSTOPERATIVE TREATMENT. 

tion the abscess is frequently emptied by pressure applied to it from 
the front, and is allowed to fill again and to be emptied again. The 
patient's position, also, is altered many times. He is turned over toward 
the sound side, and is then turned almost upon the back, in order that 
every part of the abscess sac may be well and vigorously flushed. 

The surgeon now proceeds to remove as much of the lining mem- 
brane of the abscess as is possible. The finger is the safest and most 
useful instrument. It is introduced as far as possible. Diverticula 
from the main abscess are opened up, collections of caseous matter 
are scraped away with the nail, and here and there the action of the 
finger may be helped by a sharp spoon. This instrument, however, 
must be used with caution. It causes bleeding, and often produces 
a needlessly extensive raw surface. Moreover, the anterior wall of 
the abscess-cavity is usually thin, and the steel instrument may inflict 
a serious injur}' upon that part of the parietes. 

Xext to the finger, the most valuable means of clearing out the abscess- 
cavity is a piece of fine Turkey sponge held in a slender, long-bladed 
holder. This should be passed in all directions over every part of 
the abscess wall. The wall should be literally scrubbed with it. It 
should be gently bored by a rotatory movement into every pocket and 
diverticulum. The sponge must be changed very frequently. 

After a vigorous use of the finger and sponge, the irrigator is again 
brought into action, and the abscess-cavity is once more flushed out, 
and such debris as the sponge has left is swept away. Once again 
the finger and thumb search out all the recesses of the abscess, and 
once again the stream from the irrigator follows. This is done until 
the abscess- cavity appears to be clean, and until the sponge is returned 
practically unsoiled. The process is slow and tedious, but it is very 
effectual. It leaves the abscess-cavity bare, and freed entirely of the 
curdy pus, of the caseous masses, and of the ill-conditioned debris 
which filled it. 

Finally^ the interior of the abscess is wiped dry with the last set of 
sponges used, and the wound is closed by a series of silkworm-gut 
sutures, passed sufficiently deep to include the greater part of the muscu- 
lar and tendinous structures with the skin. 

A pad of dry gauze or of wool dusted with iodoform is placed over 
the little wound, and is secured in position by a broad flannel bandage. 

After-treatment. — The subsequent treatment consists in absolute 
rest in the recumbent position for a period of months — a period which 



MISCELLANEOUS OPERATIONS. 323 

may easily be too short, but hardlv too lonsj. The actual number 
of months during which the recumbent posture should be observed 
must depend upon the nature, extent, and stage of the disease. In 
adults it will probably extend beyond six months in the hands of those 
who wish to exercise a wise caution. It is not the abscess which is in 
need of treatment — it is rather the diseased condition which has pro- 
duced it. 

If the period of rest can be carried out at the seaside, and the patient 
spend the greater part of the time out in the open air (winter and sum- 
mer) in a spinal carriage, so much the better. 

The abscess may refill, and may need to be evacuated, washed and 
scrubbed out, and closed a second time. 

In no case have I had occasion to carry out a third operation. If 
the wound should break down and pus escape at the site of the incision, 
free drainage and a most liberal irrigation must be the plan of treat- 
ment. This has occurred in a few of my cases, and in every instance 
the patients who have been the subject of this complication have done 
well. The wound, even in these cases, will heal by first intention, and 
signs of pus beneath the surface will usually not be observed until a 
fortnight or more has passed by. 

Barker has employed in these cases an ingenious instrument, wilich 
he terms the hollow or flushing curet. It consists of a curet with a 
tubular handle and shaft, through which water can be conducted into 
the hollow of the curet. The water, running continuously through the 
instrument, washes away all debris as soon as it is loosened by the 
sponge. 

Techxic. — The modus operandi is thus described*: A two-inch 
incision is made through sound structures over the low r er end of the swell- 
ing. Through this opening a hollow gouge is inserted, which is con- 
nected with a reservoir of hot water at 105 to no° by a rubber tube some 
six feet long. This reservoir (a three-gallon can) is raised about five 
feet above the operating table. When the water is now turned on, it 
rushes through the long gouge to the fundus of the abscess with con- 
siderable force, and the reflux carries the contents of the cavity out by 
the incision. By gentle scraping with the flushing-scoop the more solid 
caseous matter is dislodged, the hot water earning it clear of the cavity 
at once. Then the walls of the cavity are gently scraped in a methodic 
manner until the soft lining is loosened and carried away from every 
* " Brit. Med. Jour.," Feb. 7, 1891. 



324 POSTOPERATIVE TREATMENT. 

part of the abscess. In order to effect this thoroughly, the scoops are 
made of varying length, so that the deeper parts can be reached. With 
hot water the bleeding is but slight if the peeling be done cautiously. 
When the water runs out clear after having been carried to all the 
recesses of the cavity, the instrument is withdrawn. Then any excess 
of water is squeezed out ; and if the deeper parts are accessible, sponges 
are used to dry out the last traces of moisture. Then two or three ounces 
of fresh iodoform emulsion is poured into the deepest part of the abscess, 
and stitches are inserted in the edges of the incision. Before these are 
knotted, all excess of emulsion should be squeezed out of the cavity. 
The knotting of the silk sutures then completes the procedure. As no 
drain-tube is used, a simple dry dressing of salicylic wool is alone re- 
quired; but it should be laid on in considerable quantity, so as to exert 
elastic pressure over the « whole area of the abscess when bandaged. 
Such a dressing may be left on for about ten days, when it is time to 
remove the stitches, and the wound should then be firmly healed. A 
piece of salicylic wool secured by collodion at the edges should, however, 
be laid over it, to keep it from chafing, for a few days longer, and the 
elastic pressure also should be kept up. 

BUBO. 

Technic. — When suppuration is marked, the pus should be evacuated 
by free incision, and at the same time all portions of the glandular 
structure should be removed by means of careful dissection with a sharp 
curet. The wound is left open and packed with iodoform gauze and 
allowed to heal by granulation. It requires from two to four weeks 
ordinarily for the wound to heal. 

Considerations of Time. — Surgeons disagree as to the proper time of 
extirpating or incising the gland. The majority prefer to wait until 
suppuration is well marked and the gland is entirely broken down 
before any incision is made. For this reason Krulle advises the appli- 
cation of hot fomentations till the gland is entirely broken down, when 
the pus is evacuated through a small incision. Every second day the 
pus is then squeezed out and the cavity of the wound washed with a i 
percent solution of silver nitrate. Under this treatment the patient can 
walk about and thus avoid the necessity of lying in bed. This method 
is only applicable to cases in which the glands break down rapidly, 
but in many instances suppuration goes on slowly, in which case it is 
better to make a free incision, evacuate the pus, and remove by curetment 



MISCELLAN l-.OUS OPERATIONS. 



325 



the broken down remains of the gland. When healing is delayed, gen- 
eral tonics are indicated, and the local use of balsam of Peru or ichthyol 
applied upon the gauze packing may prove of great benefit. 

Harden waits until pus forms, then through a small incision squeezes 
out the pus, washes the cavity out with hydrogen peroxid, then flushes 



k. 




Fig. 91. — Removal of Gasserian Ganglion after Lexer. 
Shows the incision, the lines which limit it, the flap turned down and the exposed ganglion 

after removal of the bone. 



out with a bichlorid solution, injects warm iodoform ointment, and 
dresses with cold moist bichlorid gauze to congeal the ointment. 

EXCISION OF THE GASSERIAN GANGLION. 
Postoperative Treatment. — In a prolonged and difficult operation of 
this kind faults in asepsis are apt to creep in, as shown by the fact that 



326 



POSTOPERATIVE TREATMENT. 



about half the fatal results are due to septic meningitis. At the end of 
the operation, therefore, the wound should be gently flushed with a 
weak warm antiseptic solution. There is always much oozing during 
the operation, and nothing could be worse than the collection of blood 
between the dura and the flap. Hence, whether the large trephine has 
been used or the osteoplastic method, provision should be made for 
drainage during the first forty-eight hours, and the patient's head 
should be turned on the affected side. A small piece of iodoform gauze, 
removed in two days' time, will suffice. The head must be enveloped 
in a fight dressing of sterilized gauze and wool, and for securing it 
an elastic bandage is useful, or a modified Barton or recurrent bandage 
(Wharton) may be employed. 

The wound should heal in a week; but if bone has been replaced 
or the osteoplastic method' employed (see Fig. 92), it may happen that 
necrosis will occur. If the ganglion is removed by avulsion or otherwise, 




Fig. 92. — Osteoplastic Flap Turned Down, showing Dura Mater, Meningeal 
Artery, Exposing Gasserian Ganglion, etc. — {Brewer.) 



it not only severs connection between the root and the second and third 
divisions, but also between the root and the first division as well. It 
then follows that the eye will be anesthetic, dryness, friction, and foreign 
bodies are not perceived, and abrasion, corneal ulceration, and loss of 
the eye may follow. (See Fig. 93.) Keen says to avoid this just 
before the operation is begun it is best to sew the eyelids together to 
protect the ball, the sutures being removed on the third day. A celluloid 



MIm 1 1 1 WKOl'S OPERATIONS. 



3 2 7 



shield, similar to the vaccination shield, and devised bv Keen, is then 
fastened in front of the eye by clastic, and is worn for a week or more, 
the eye being syringed daily with a warm boric solution. 

For this reason, and also on account of the success of the operation 
limited to the two main divisions of the fifth nerve and the ganglion, 




Fig. 93. — Shows Postoperative Facial Paralysis Following Removal of the 

Gasserian Ganglion; ( i) Line of Incision; (2) Area of Anesthesia. — Van Hook. 

("Journal S., G. and Obs.," Vol. ii, No 1.) 



the operator is advised to let the ophthalmic trunk and the ganglion 
alone; if this advice be followed, no precautions are required as regards 
the eye. 

Postoperative shock may be considerable in these patients, who 
are usually aged and exhausted by their suffering, and it has accounted 
for nearly half of the deaths recorded. In overcoming it, adrenalin 



328 POSTOPERATIVE TREATMENT. 

and strychnin injections, brandy and coffee enemas, and a warmth to 
the general surface are the chief remedies. 



LAMINECTOMY. 

In closing the wound when the cord has been exposed some surgeons 
prefer not to close the theca or outer covering of the cord, but leave it 
open in order to prevent pressure. If carefully sutured, however, it 
tends to prevent loss of cerebrospinal fluid, and if left open cicatricial 
adhesions of the soft parts to the surface of the cord may occur. A 
drainage-tube is usually placed in the muscular portion of the wound 
to carry off the wound fluids for the first twenty-four to thirty-six hours. 
Unless for very urgent reasons the drainage-tube should not remain 
longer. The muscles and subcutaneous tissues are usually approxim- 
ated by buried sutures, and skin closed by silkworm-gut, and the usual 
antiseptic dressings applied and held in place by ordinary binders. 

The position of the patient after the operation should be dorsal, 
which affords sufficient drainage and prevents escape of the cerebro- 
spinal fluid. The limbs and body are elevated, and borated starch or 
zinc stearate should be liberally applied should the fluid discharges 
irritate the skin. 

After-treatment. — On account of the abundant oozing both of the 
wound-fluids and possibly of the cerebrospinal fluid, the wound will usually 
have to be dressed within the first twelve hours, but after the first twenty- 
four hours not usually more than once in two or three days. The 
strictest antisepsis should be observed, lest infection should follow. 
This is particularly necessary, both during the operation and the after- 
treatment, if there are bedsores, since they produce considerable foul 
discharge which may infect the wound. If the patient has lost control 
of the bladder and bowels, an additional source of infection exists 
which will require great vigilance. 

Thorburn has proposed to drain the bladder by suprapubic cystotomy 
after injury of the cord, to avoid the constant wetting of the wound, 
and its infection through the incontinence of the urine. The supra- 
pubir route is selected, inasmuch as these parts are not anesthetic and 
therefore not apt to slough. The suggestion seems to be very reason- 
able, but I have seen no report of it having been carried into practice. 
The bedsores should be dressed with boric ointment, carbolated vaselin, 
or such other mild ointments. They often show very remarkable and 



Misci l l \\i di s OPEK \ riONS. 329 

early improvement, and not uneommonly heal entirely. Of course, 
the usual precautions as to food and drink must be observed, together 
with the use of opiates for sleep and such other symptomatic treatment 
as may bo required. (Dennis.) 

SPINA BIFIDA. 

The radical cure of spina bifida is now more frequently attempted 
than formerly. The choice of methods for removal of the tumor by 
dissection, ligation, or excision must depend upon the size, local condi- 




Fig. 94. — Spina Bifida (Original). — ("American Text-book of Surgery.") 

tion of the formation or growth, and the general condition of the child. 
If the tumor is large or the cord or cauda equina is involved, usually no 
attempt at removal should be made. Pedunculated cysts, where the 
opening in the lamina is small, may be safely removed. After removal 
or extirpation a double layer of iodoform gauze is placed over the w r ound, 
after which the entire wound and area well around the incision should be 



33° POSTOPERATIVE TREATMENT. 

hermetically sealed by means of collodion and cotton. Over this at 
least two layers of rubber tissue should be placed and sealed to the skin 
about its edges with chloroform, and, lastly, over all a layer of cotton is 
placed, with plain gauze, and all held in position by a broad abdominal 
bandage. 

The after-treatment of these cases is of vital importance. The 
child is placed in bed upon its stomach, with no pillow under the head. 
This position should be maintained for several days or weeks, or until 
thorough healing has so far progressed that all leakage of cerebrospinal 
fluid has ceased. Excessive loss of cerebrospinal fluid is manifested 
by sinking of the fontanels. 

Nourishment, with alcoholic stimulants, should be administered 
freely, as death from exhaustion is of very frequent occurrence. De- 
pressed fontanel, tetanic convulsions, however slight, preceded by 
vomiting, usually indicate a fatal termination. 

HYPOSPADIAS OR ECTOPIA VESICA. 

General Considerations. — Parker keeps his patients in a hip-bath 
of warm boric lotion throughout the whole of the after-treatment, with 
the result that almost complete primary union follows a flap operation. 
With care the position of the patient in a hip-bath may be made so com- 
fortable that he will rest better in the bath than in the constrained and 
cramped position he must of necessity occupy in bed. The discomfort 
of lying upon a wet mackintosh is also not inconsiderable. 

It is needless to say that the lotion in the bath must be maintained 
at an even temperature, and be constantly changed. Thiersch and 
others advise the use of a Compress* after the operation has been quite 
completed. This instrument is intended to occlude the newly made 
urethra, and to be removed when required. 

It cannot be recommended, on these grounds: in the first place, the 
capacity of the new bladder is very small; and in the second place, the 
constant pressure of the instrument is capable of producing a slough 
or even a urinary fistula. 

In the most successful cases a urinal cannot be dispensed with. 

Results of the Operation Generally. — The results claimed in the 
most successful cases are that the raw surface of the bladder is protected 
and covered in, and that a urinal can be worn which will keep the patient 

*An instrument devised for making pressure over the new-made urethra. 



MISCE] 1 ^NEOUS OPERATIONS. 



33* 



quite dry. Many patients are free from the inconvenience of incon- 
tinence when they arc lying down, but in no instance can it be claimed 
that the patient has acquired a control over the bladder. These results, 




Fig. 95. — X-ray Photograph Showing the Result of Pubiotomy Taken Immedi- 
ately FOLLO'tt'ING THE BlRTH OF THE CHILD. THE CONJUGATE DIAMETER HAVING 

been Increased Two and One-Quarter Inches. 



however, are very satisfactory when the miserable condition of the 
patients before the operation is considered. (Treves.) 



SYMPHYSIOTOMY. 

General Considerations. — After the completion of the labor, the 
wound should be thoroughly cleansed with sterile water, and lastly 
alcohol. Three or four stout silk, silver- wire, extra large silkworm-gut, 
or preferably heavy kangaroo tendon sutures are used to hold in appo- 
sition the separated bones. The sutures should be inserted at least 
one-half inch from the margins of the muscular insertion, and should 
include all the fibrous tissue down to and including the periosteum. 
Thev are tied in the median line, cut short, or buried. The superficial 



33 2 



POSTOPERATIVE TREATMENT. 



incision may then be closed after the ordinary method, small rubber 
tissue drainage being indispensable. 

The wound is dressed with several layers of iodoform cloth with a 
layer of Wood's or absorbent cotton, all of which are held snugly in posi- 
tion by means of a broad moleskin adhesive plaster passing around the 
pelvis immediately below the crest of the ilium, and extending down 
over the trochanters in order to retain the pelvic bones in apposition. 
The patient is now placed upon a gutter-shaped bed or mattress, with 
cushions under the lateral halves of the body. Jewett and others adopt 







Fig. 96. — Ayres' Symphysiotomy Hammock, Showing Patient. — {Jewett.) 



practically the same method, using an ordinary hard mattress and 
keeping the patient on two firm cushions placed under the lateral halves 
of the pelvis and extending nearly to the shoulders. 

Mechanical Aids. — An excellent apparatus for maintaining coap- 
tation of the pelvic bones after symphysiotomy is Ayres' hammock bed. 
This consists of a canvas stretcher supported as shown in Fig. 96. The 
stretcher may be made more or less trough-like by adjustment at shorter 
or longer distances apart of the poles on which it hangs. A canvas 
slide wide enough to reach well above and below the pelvis is suspended 



I4ISCELLANE0US OPERATIONS. 333 

by its ends from a second scries of poles above the first. The patient 
rests with her pelvis in the loop of the sling, while the remainder of 
her body is supported by the stretcher. It will be seen that the pubic 
bones are held firmly in apposition by the action of the sling. 

The author has used an ordinary hospital bed with high frames and 
woven wire mattress to accomplish the same purpose. The stretcher 
bolts of the mattress in the center are loosened with an ordinary wrench. 
If necessary, the two outer bolts of the wire mattress may be drawn very 
tight. Over this is placed an ordinary cotton mattress. Two poles 
are then adjusted above the patient similar to the mechanism of the 
Avers' bed (Fig. 96). 

When the bedpan is used, the greatest care must be exercised by the 
nurse to see that no movement of the bones is permitted. The sling in 
which the patient lies should not be removed, but the thighs may be 
gently lifted while the nurse slips the vessel beneath. The patient 
should remain in bed fully six weeks, the case being treated as in fracture 
of the pelvis. The pelvic support should not be discarded for three or 
four months after the woman leaves ber bed. 

REMOVAL OF VARICOSE VEINS OF THE LEG. 

Mayo's method of procedure is as follows: The vein is sought for 
and severed in the upper third of the thigh. The proximal end is ligated, 
the low r er end is passed through the ring of the enucleator or placed in 
the ring of the forceps, and clamps are placed on the end of the vein. 
By a gentle pushing force, the vein being held to make tension and the 
tissues steadied on either side by an assistant, the ring of forceps is 
pushed down the vessel for six or eight inches, tearing off the lateral 
branches, when the point of the instrument is forced against the skin 
from beneath and a small incision is made to the ring of forceps, which 
is pushed through the opening, holding the vein like a thread in a needle's 
eye. The vein-loop is drawn out of the opening and also from the instru- 
ment, which is removed, rethreaded on the vein, and again forced through 
the new opening, following the vein, and is pushed down to a lower 
point, where the small incision is again made and the process of removal 
repeated. The small lateral branches are torn off, and, as a rule, have 
enough muscle structure to close themselves. Should the main venous 
trunk break, a new incision is made below the knee, the vein exposed 
and divided, and the enucleation made in both directions from this 



334 



POSTOPERATIVE TREATMENT. 



point. Below the knee the branches are larger and the vein is more 
adherent, being more superficial, so that a shorter distance must be 
traversed. 

If it is found that calcareous deposits, sacculations, or extreme weak- 
ness of the walls render the case unsuited to the enucleation method, 
and this occurs in about ten percent of the cases, the principle of opera- 
tion should then be changed to an open method, undermining only the 
section by the knee. 

Hemorrhage is avoided, first by position. An ordinary gynecological 
standard is placed in position and supported by the ankle. The position 




Fig. 97. — Mayo's Method for Removal of Varicose Veins of the Leg. 



renders the limb partially bloodless, and also secures elevation and 
accessibility of the field of operation. Should any branches cause more 
than ordinary 7 hemorrhage, it can be checked by a pressure-pad, held 
against the skin over the region from which the veins were removed, 
or by small packs, which are left for a few minutes in the incision from 
which it arises. 



M1SCKI.LANE0US OI'KKATIONS. 335 

When necessary to skin-graft an excised ulcer, we apply a twisted roll 
of gauze about the leg above and below the grafted area to support a 
sheet of sterile celluloid or wire gauze held in place by a strip of adhesive. 
The final bandage is applied from the foot to the body, and a small 
area is cut out over the protective. This serves as a window through 
which to watch the condition of the graft, which usually unites with 
one dressing. 

The method outlined has reduced the time for operation very con- 
siderably, and has placed it in the class of relatively trivial operations, 
when uncomplicated by sepsis or embolism. 

Should there be a persistent eczema in spite of previous preparation, 
the operation is proceeded with as usual, the ulcer being excised before 
enucleation of the vein. The ulcerated area is skin-grafted. The 
eczematous area is now painted with compound tincture of benzoin or 
an acetone solution of guttapercha after Murphy's plan, which acts 
as an aseptic varnish, literally sealing this surface until the incisions 
have themselves become sealed against infection. Mild antiseptic 
dressing is applied, and the leg is placed in an immovable splint and 
maintained in a somewhat elevated position for twelve days. The 
patient is then allowed to get up, wearing an elastic porous supporting 
bandage for a few months. 

The causes of recurrence are usually the result of a widening of the 
collateral veins, formation of new veins, and, it is claimed, from regen- 
eration of the saphenous itself. It is probable, in the latter cases, that 
the more superficial and smaller vein often noticed in the same region 
has been removed or has dilated and practically formed a new saphenous. 
The dangers are from pulmonary embolism, which Goerlich reports as 
recurring twice in 108 cases in Von Brun's clinic. Sepsis is rare, although 
a serious possibility, and difficult to guard against in some cases with 
ulcer and eczema. 

TUBERCULOSIS OF THE JOINTS. 

This condition is characterized by slow beginning, by its usual limi- 
tation to one joint, by the tendency to fixation of the joint, and, lastly, 
by the atrophy of the muscles both above and below the affected part. 
(Ochsner.) 

Rest Cure. — It is of the utmost importance that the surgeon's atten- 
tion be primarily directed toward the improvement of the patient's 



336 POSTOPERATIVE TREATMENT 

general condition, which can be best accomplished by improving the 
hygienic surroundings, the nutrition, and regulating the habits of life; 
and by administering tonics and concentrated foods and some form of 
creasote. Above all things, the patient should not be permitted to 
continue to live under the condition which primarily gave rise to the 
disease. These points are of great importance, not only in obtaining a 
recovery from immediate disease, but also for the purpose of securing a 
permanency of cure. It frequently becomes necessary to change the 
dwelling of these patients, if not the climate, to change their food, to 
regulate their hours of rest, and frequently their occupation. 

This accomplished, the treatment of the joint involved depends 
upon its location and the extent to which the disease has progressed. 
If in the incipient stage, rest alone, with the conditions described above, 
will frequently suffice to produce a recovery. (Senn.) 

Mechanical Aids. — A light cast made of plaster-of-Paris, very care- 
fully constructed and strengthened by thin strips of wood-fiber, is 
usually the most desirable dressing, unless the patient can afford the use 
of similar dressings manufactured from aluminium. The cast should 
be applied over some elastic woven material arranged in a double layer 
in order that the friction of the cast which adheres to the outer layer will 
not be directly against the skin, but against the second layer which will 
remain free. If the joint of the ankle or knee is involved, it is best 
to draw two closely fitting stockings upon the extremity. The cast 
should be worn for three or four months after the joint is apparently 
well. In the case of a hip-joint, enforced rest by fixation with a plaster- 
cast should be supplemented by the use of a weight-and-pulley extension 
to be applied at night for a period of at least two years after the joint 
has apparently fully recovered, for the reason that this plan of treat- 
ment tends to prevent recurrence. (Ochsner.) 

This also tends to prevent deformity, to increase the comfort of the 
patients, and to remind them of the necessity of avoiding traumatism 
for a considerable time. Extension is made by applying a strip of rubber 
adhesive plaster to the inner and outer surface of the entire thigh and 
leg, holding them in place by a roller bandage. These plaster strips 
are attached to the cord which passes over the pulley to the weight. The 
lower end of the bed should be elevated sufficiently to secure counter- 
extension from the weight of the body. The amount of weight to be 
employed may be determined best by the comfort of the patient. 

Operation Upon the Joints. — After the diseased bone and tissue 



MISCELLANEOUS OPERATIONS. 337 

has been completely removed, the raw surfaces all should be thoroughly 
and repeatedly swabbed with a 95 percent solution of carbolic acid for 
a period of five minutes, then the superfluous acid should be washed 
away with strong alcohol. After this it is the custom of some surgeons 
to apply strong compound tincture of iodin to the entire surface, and, 
lastly, a 10 percent solution of iodoform and glycerin, after which the 
wound should be closed with deep sutures of catgut and superficial 
sutures of any desired material. If doubt exists as to the aseptic con- 
dition of the joint when the operation has been completed, the same 
should be freely drained with rubber tubes or with iodoform gauze passed 
transversely through the articulation. The joint is then covered with 
a large dressing and immobilized by means of splints or plaster-of- 
Paris. 

Treatment of Tuberculous Abscess of the Hip-joint. 

English Method — Cheyne-Treves. — After free incision the abscess 
wall is clipped away, and by means of Barker's flushing spoon the abscess 
cavity thoroughly scraped and cleared out. The addition of flushing 
with hot normal salt solution to the use of a sharp spoon is a great 
safeguard against the risk of general infection which accompanies scrap- 
ing alone. As the material is scraped away the rush of fluid through the 
instrument washes out the wound at once, and thus prevents infection 
being carried into the circulation. After the abscess has been scraped 
out, an ounce or more of 10 percent solution of iodoform and glycerin 
is injected into the cavity, the wound closed without drainage, and anti- 
septic dressings applied. The successful treatment depends upon 
strict asepsis. Should the wound become septic, good results cannot be 
expected from treatment of abscess alone. Should sepsis occur, serum 
may collect and the wound be distended, in which case, if there be 
fluctuation, the wound must be opened and the fluid evacuated. Effort 
should be made to heal the wound by granulation. 

Should a sequestrum be felt when the abscess is opened and scraped, 
or should a cheesy deposit in the bone be easily reached, it should be 
removed, but any further attempt to clear out the joint at this stage is 
unnecessary and should be avoided. (Cheyne-Burghard, "Manual 
of Surgical Treatment.") 

When there are Septic Sinuses. — When septic sinuses are present, 
the conditions are altogether different, and in most cases excision is 
advisable. W T hen the position of the limb is good and the patient's 



338 POSTOPERATIVE TREATMENT. 

general health is satisfactory, and when there are only one or two sinuses, 
an attempt may be made, by proper fixation of the limb and the estab- 
lishment of good drainage, to bring about a cure of the disease. All 
sinuses should be enlarged and their tracks thoroughly scraped, undiluted 
carbolic acid being applied to the whole length of each sinus before 
finishing the operation. When possible, if two or more sinuses can be 
made to communicate, a large drainage-tube should be passed through 
from one opening to the other, or the incision should be sufficiently free 
to include both, after which a large drainage-tube should be introduced, 
reaching down to the bone. 

Atter-treatmext of these cases will consist of complete fixation of 
the joint and careful dressing of the sinuses. The best method of fixing 
the joint is to apply a plaster-of-Paris splint, in which suitable openings 
are left for dressing the sinuses; the plaster should extend up over the 
lower ribs. It should be strengthened both in front and behind the hip, 
either by strips of metal incorporated in the bandage or by strands of 
tow thoroughly impregnated with plaster. Below, it should reach to the 
upper part of the calf, so as to fix the knee-joint as well as the hip, and 
it should be applied with the limb in a position of abduction. When the 
sinuses are situated so that it is difficult to apply the bandage without 
covering them, metal bars bent outward opposite the wound may be 
incorporated with the bandage so as to provide a firm splint, and at the 
same time to give sufficient interruption in it to allow access to the 
wound. 

The draixage-tubes should not be removed for at least a week, as 
otherwise there may be some difficulty in reintroducing them. When 
two sinuses have been made to communicate, and a tube has been passed 
from one to the other, a long loop of silk should be inserted into each 
end of the tube, and then, when it is desired to wash the latter, it will be 
easy to reintroduce it, because one end can be pulled upon until a con- 
siderable amount of the tube has been withdrawn; this portion can be 
washed with a 1:2000 sublimate solution, and, by traction upon the 
second loop, the other end of tube can be made to project, until the 
whole tube has been thoroughly washed, when traction on the first loop 
will pull the tube into position again. After cleansing the tube it is well 
to dust it with iodoform before it is put back into position. We do not 
consider that these tubes should be svringed out with any antiseptic; 
the only result of this is to irritate the woimd without doing any good. 
After about three weeks the tube mav be cut in two and shortened, so 



MISCE1 LANEOUS OPERATIONS. 339 

that the outer end of each lies Hush with the skin, while the deeper one 
goes to the bottom of the cavity. As healing t a kes place from the bottom, 
the tubes will be gradually pushed out and must be cut down. When 
a very large tube has been used at first, a somewhat smaller one may 
be substituted later. 

When the tube has been passed into each of the sinuses they should 
not be disturbed for about a week. Each tube may then be withdrawn, 
cleaned, powdered w r ith iodoform, and replaced. In all cases the tubes 
should be kept in as long as possible, and, when it is found that the 
large tube will not pass to the bottom of the sinus, one of smaller caliber 
must be substituted. It is well to substitute a fresh tube every few days, 
as granulation tissue grows through the holes and blocks the lumen. 
In the fresh tube the holes will be in a different position, and the diffi- 
culty is thus easily avoided. 

In a certain number of cases, unfortunately few, the sinuses heal and 
the disease may be cured when the patient is under good hygienic con- 
ditions and carefully treated; but when there are a number of sinuses 
and when sepsis is marked, the attempt, as a rule, ends in failure, and 
it will be necessary to excise the joint. In other cases in which the disease 
is evidently active, and it is obvious that the patient cannot be placed 
under good hygienic conditions, it is well to excise the joint at once. 
Before proceeding to excision, the sinuses should be thoroughly scraped 
and sponged with pure carbolic acid, so as to render the wound as 
nearly aseptic as possible before the excision is performed. 

Use of Carbolic Acid in Tuberculous Abscess. — Carbolic acid 
in dilute solutions was at one time injected into tuberculous cavities, 
but its use has been generally discontinued because of the danger of 
poisoning. Recently Phelps has advocated the use of pure carbolic 
acid in the treatment of tuberculous abscesses and sinuses. This is 
injected into the fistula or into the abscess cavity, which has been opened, 
and is allowed to remain for about a minute, when it is neutralized by 
copious injections of alcohol, after which the part is thoroughly cleansed 
by salt solution. Carbolic acid doubtless acts as a caustic, destroying 
the infected granulations and stimulating the reparative processes. 
Other remedies of this class — for example, tincture of iodin, zinc chlorid, 
actual cautery, and the like — are also used, and in certain cases with 
benefit. In the treatment of tuberculous ulcerations ichthyol, balsam 
of Peru dissolved in castor oil of a strength of 10 percent, as suggested 
by Van Arsdale, is a satisfactory application. 



340 POSTOPERATIVE TREATMENT. 

Venous Stasis — Bier's Treatment. — Bier's treatment of tubercu- 
lous joint disease was suggested by the observation of Rokitanski, that 
phthisis was uncommon in individuals suffering from disease of the 
heart when the mechanical obstruction was sufficient to cause venous 
congestion of the lungs. 

Treatment by means of venous stasis is conducted as follows: A 
rubber bandage is placed about the limb above the joint, under sufficient 
tension to interfere with the return of the venous blood; and in order 
to limit the congestion to the diseased part, the limb is firmly bandaged 
with a flannel bandage up to the joint, from below. Between the two 
the tissues about the joint become swollen, the local temperature is 
increased, and the color of the skin becomes bluish-red. At first the 
congestion is continued for short periods only during the day, as it is 
somewhat painful. These are lengthened, until finally it may be applied 
continuously. 

If the disease is active, the treatment may hasten abscess formation; 
and if sinuses are present, the discharge is usually increased for a time. 
The venous congestion is supposed to stimulate the formation of healthy 
granulations and their further transformation into fibrous tissue; and 
according to the investigations of Hamburger, the serum of venous 
blood has a distinct germicidal property. The treatment may be applied 
most conveniently at the knee-joint and ankle-joint, but if applied, it 
should serve merely as an adjunct to mechanical protection. 

Iodoform-glycerin Injections of Tuberculous Joints. — A 10 percent 
solution of iodoform in glycerin has been very much extolled in the 
treatment of tuberculous joints. Ochsner lays down several points 
in the technic which should be carefully obeyed: 

"i. The trocar should never be plunged directly into a joint, but 
always obliquely underneath a fold of skin, so that a valve will be formed 
when the trocar is withdrawn, which will prevent infection of the joint- 
cavity with pathogenic microorganisms. 

11 2. The amount of pressure employed in injecting the solution should 
be moderate in order to avoid rupturing the capsule of the joint and 
forcing the fluid, together with tuberculous contents of the joint, into 
the tissues surrounding. 

"3. The amount of manipulation should be limited, in order to 
prevent the opening of lymph- spaces through which secondary infec- 
tion might occur. 

" 4. If the treatment does not result in distinct benefit to the patient 



MISCELLANEOUS OPERATIONS. 34I 

after live or six applications from one to two weeks apart, it should be 
abandoned. 

"5. The patient's general and hygienic influences must be improved. 

"6. As much as possible of the fluid contained in the joint should 
be withdrawn before the injection is made. 

"7. Except in the shoulder and in the sacroiliac joints, an Esmarch 
constrictor should be applied before the joint is tapped, and left in place 
until a large dressing has been fitted and held in position by a snug 
bandage, which will prevent hemorrhage into the joint. 

"This last precaution is not generally employed, but I am confident 
that it is of distinct benefit. 

"In inserting the trocar into the various joints, aside from carefully 
securing a valve formation of the canal, the surgeon must avoid injuring 
important anatomic structures in the vicinity of the joint, and the point 
of the trocar must be directed so that it will not injure any joint surface. 

"In the smaller joints a very small amount of the solution may suffice, 
the quantity employed depending upon the tension caused by the fluid 
injected, which should never be sufficiently great to endanger the 
capsule or to produce severe pain. In the wrist-joint the introduction 
of the fine trocar used is usually not followed by the evacuation of any 
fluid, and here the injection of 2 to 4 c.c. will often be followed by good 
results. In the knee-joint it is often possible to withdraw several 
ounces of fluid, and in cases it is safe to inject as high as 30 or 40 c.c. 
of the iodoform-glycerin solution. 

"In order to prevent too great tension in injecting this solution into 
tuberculous joints, it is well to attach a soft-rubber tube to the trocar 
with one end, and to a glass syringe holding 20 c.c. with the other, 
and then to pour the solution into the glass syringe and to introduce 
the plunger after the rubber tube and the trocar have become filled 
with the solution spontaneously. In forcing in the plunger, if the 
pressure becomes too great, the intervening rubber tube will become 
dilated before a sufficient amount of pressure has been exerted to injure 
the capsule of the joint. In injecting the large joints a large trocar is 
used, but in the smaller joints the trocar should be just large enough to 
permit the transmission of the iodoform." (Ochsner's "Surgery.") 

After-treatment. — Until the pain has subsided the patient should 
be kept at rest; then a moderate amount of exercise is useful. The 
injection is repeated every one to two weeks at first, and less frequently 
later. 



342 POSTOPERATIVE TREATMENT. 

Whitman's Methods of Treatment,* etc. — Tuberculous abscess 
is a symptom and common accompaniment of hip disease, which, in 
cases treated under proper conditions, is not of great importance; and 
yet, on the other hand, it is recognized as a dangerous complication. 
It is dangerous to life because of the profuse suppuration that may follow 
infection, and to function because of the adhesions and contractions that 
may result. 

The Significance of Abscess. — If abscess appears early in the 
course of the disease, it usually indicates that it is of a destructive 
character and that the interior of the joint is involved, therefore perfect 
function is less likely to be preserved than in those cases in which the 
disease has been confined to the interior of the bone. 

In certain instances abscess formation is preceded by an acute exacer- 
bation of symptoms, by pain, by an increase of muscular spasm and 
consequent distortion, and often by an elevation of temperature. These 
acute symptoms subside and a fluctuating swelling appears. It may be 
inferred that the pain in such a case was due to the tension of the abscess 
within the capsule, and that the relief of pain followed perforation and 
the escape of the fluid. 

Treatment. — Some surgeons have advocated absolute noninter- 
ference with the symptomatic abscess on the ground that in many 
instances it finally disappears by spontaneous absorption ; while in other 
cases the long delay allows the communication with the joint to close, 
so that the danger of infection after an opening has formed is slight. 
Finally, that the results after noninterference are better than those reported 
after operative treatment. Others insist that all collections of fluid 
of this character should be evacuated when they are discovered, because 
of the danger of infection before an opening forms and because of the 
advantage gained by preventing burrowing of pus. There would be 
little to be said against this latter course were it not that infection is as 
common .after operative treatment as when a spontaneous opening 
forms; the only advantage in favor of the artificial opening being that 
the cavity with which it communicates should be smaller than when 
the incision has been long delayed; but this is offset by the fact that at 
least 20 percent of abscesses disappear without treatment. In fact, 
as compared with indiscriminate incisions, when proper precaution 
and care cannot be assured, the let-alone treatment should be preferred. 

It would appear, however, that the middle course — between the 
*" Orthopaedic Surgery,'' Whitman. Lea Brothers & Co. 



Misei i i \\i ;01 s OPERATIONS. 343 

extremes — is the safest, and especially SO as by far the larger number of 
patients must be treated under conditions which do not admit of proper 
care. In the outdoor department of the New York Hospital for Rup- 
tured and Crippled abscesses are treated symptomatically. If a swelling 
appears but remains quiescent and causes no symptoms, it is not dis- 
turbed. If it enlarges, the tension of the fluid is relieved by aspiration, 
which may be repeated as required, compression, after the evacuation 
of the fluid, being applied by a pad and bandage. If the abscess is on 
the point of finding a spontaneous opening, or if its contents are of such 
a nature that aspiration is impossible, an incision is made and the proper 
dressings are applied ; or, if the child lives at a distance from the hospital, 
the mother is instructed in the manner of dressing and as to the impor- 
tance of cleanliness. If the abscess is of large size, or if acute symp- 
toms are present, the child is admitted to the hospital. Here the same 
general principle is followed, but at the present time the routine of 
treatment of noninfected abscess is free incision, that will allow com- 
plete evacuation of its contents. The abscess membrane is removed 
by gently rubbing with iodoformized gauze. 

If the opening in the capsule of the joint is exposed, this may be 
enlarged to permit evacuation of the products of disease within the 
joint; the wound is then closed with superficial and deep sutures and 
a firm dressing applied. This operation, if performed under aseptic 
precautions, causes no disturbance, and it removes necrotic material 
which must be an obstacle to spontaneous absorption. In many 
instances the abscess is permanently cured, although if the condition 
that induced the abscess remains unchanged, fluid will again accumu- 
late, and if so a spontaneous opening will form at the site of the operation. 
This operation is not a radical cure of the abscess or of the disease; 
it is simply a means of thorough evacuation for the purpose of accom- 
plishing what the aspirator does only in part. If the abscess has become 
infected, its contents are completely removed ; the wound is then packed 
with gauze and provision is made for efficient drainage. 

In the treatment of abscesses the injection of iodoform emulsion, 
in connection with the aspiration, has been thoroughly tested. The 
results, so far as the disappearance of the abscess is concerned, are 
not as good as from simple aspiration; and as the procedure, being 
somewhat of the nature of an operation, causes the patients some dis- 
comfort and anxiety, it has been discontinued in the practice of the sur- 
geons here quoted. From the clinical standpoint there is little evidence 



344 POSTOPERATIVE TREATMENT 

that these injections exercise any particular influence upon the disease, 
but theoretically iodoform should lessen the infectiousness of the tuber- 
culous fluid, and there appears to be no serious objection to its use. 

The most important element in the postoperative treatment of abscesses 
of the hip is the prevention of contraction and subsequent deformity 
of the limb, as well as the correction of or reduction of the deformity 
in neglected or resistant cases. In nearly all large abscesses of the 
hip more or less structural changes and shortening of the muscles 
and contracture of the surrounding tissues are necessary concomitants 
of the disease. Fibrous tissues may form with contraction of the muscles 
to such an extent as to destroy the functions of the limb. The head 
of the femur, or what is left of it, may be dislocated, and the limb be 
fixed in such a position as to require forcible reduction under anes- 
thesia, or osteotomy may be necessary. It should be remembered 
that deformity is not actually the result of a disease, but rather negli- 
gence on the part of the surgeon who fails to recognize the importance 
of prevention. After the reduction of the deformity, regardless of the 
method employed, the limb should be fixed in a long spica bandage 
and held in this position by this or other fixed appliances until the ten- 
dency to deformity has been overcome. 

The Relative Efficiency of Traction and Splinting. — Fixa- 
tion. — In considering the vexed question of the relative merits of 
splinting and traction in preventing subsequent deformity, muscular 
spasm, and the consequent intra- articular pressure which causes pain 
and increases the destructive affects of the disease, these facts must 
be borne in mind. 

When the patient is fixed in the recumbent posture it is possible to 
apply sufficient traction upon the muscles to prevent the contraction 
that causes injurious pressure, and although no amount of traction 
will absolutely prevent motion, yet with the support that the bed provides, 
practically speaking, complete rest may be assured. Only in the excep- 
tional cases in which the tension upon congested tissues about an acutely 
inflamed joint is intolerable is this method of treatment inefficient. 

The same statement is true of a properly applied spica bandage or 
Thomas brace, when the patient is recumbent, that it assures practical 
rest; thus it prevents muscular contraction, relieves the symptoms, 
and promotes repair, although it cannot be claimed that the surfaces 
of the opposing bones are actually separated from one another. 

But what is true when the patient is recumbent is not true of ambula- 



MlMill wr.oUS OPERATIONS. 345 

tory treatment. The traction exerted by the hip splint even when the 
limb is pendant is far less effective than in recumbency, and when it 
is used as a walking appliance, for which it was designed and for which 
it is practically always employed, the traction is intermittent and of 
doubtful efficiency. The same loss in efficiency in less degree occurs 
in all forms of fixative apparatus when used in ambulation. 

The Removal of Direct Pressure. — "Stilting." — Granting 
that the traction brace as a walking appliance is relatively inefficient 
in preventing motion, and that motion without friction, provided the 
joint surfaces are actually involved, is impossible, still it cannot be denied 
that the traction brace is, or may be, at all times an effective stilt in that 
it protects the joint from concussion and pressure by removing the foot 
from contact with the ground, and prevents displacements or deformity. 

It is true that the removal of direct pressure may be attained by the 
use of axillary crutches, but in Thomas' practice they were used in but 
few cases. In fact, it is only by constant supervision that the use of 
crutches can be enforced upon children who no longer suffer pain, 
and as it is practically impossible to prevent the patient from bearing 
weight upon the limb, stilting by this means is relatively inefficient. 

That direct pressure is one of the causes of upward displacement 
of the femur may be inferred from the statistics of Sasse and Bruns, 
from the surgical clinics of Berlin and Tubingen, where the routine 
of treatment is the plaster bandage, without the high shoe or crutches. 
In two-thirds of Sasse's and in four- fifths of Bruns' cases there was 
upward displacement of the trochanter. This is certainly a larger 
proportion than would be found in a corresponding number of patients 
treated by efficient stilting, although statistics on this point from Ameri- 
can sources are lacking. 

In the final comparison of the claims of traction and fixation it is 
of interest to note that the most enthusiastic advocate of the Thomas 
treatment in this country was trained in the use of the traction hip 
brace at the New York Orthopaedic Hospital and Dispensary, an insti- 
tution founded by Taylor and in wmich his methods have been closely 
followed. Ridlon states that an experience in the treatment of 11 00 
cases by the traction hip splint led him to discard it in favor of the 
Thomas brace. 

The Practical Combination of Traction Splinting and Stilting. 
— Thus far, the methods of treatment by splinting and traction have 
been presented as if they were necessarily opposed to one another in 



146 



POSTOPERATIVE TREATMENT. 



principle, and as if the theory were still held that motion without fric- 
tion is possible; and as if it were believed that ankylosis is caused by 
fixation and is prevented by the motion of a diseased joint. At the 
present time, however, it is generally recognized that the principle 
involved in both methods is the same and that the actual merit of each 
must be decided by practical experience rather than by argument. 
The true test of the relative value of a routine treatment is its efficacy 
in hospital practice, where its weak points cannot be supplemented by 
the careful supervision that may make effective almost any treatment 
that carries out in some degree the proper principle. This test is all 
the more necessary because the great majority of cases of this character 
are to be found among the poor. 

A combination of the Thomas brace and the traction hip splint 
(see Fig. 98) is the most effective mechanical means of relieving pain 




Fig. 98. — The Short Spica Bandage in Combination with the Brace. One Peri- 
neal Band has been Removed in Order to show How the Joint is Supported 
by the Bandage. — {Whitman.) 



and preventing deformity that can be employed in ambulatory treat- 
ment. It has, however, the disadvantage of requiring careful adjust- 
ment, and it obliges the patient to wear shoulder straps; in other words, 
much care must be exercised to insure the comfortable adjustment 
of both appliances. Thus the next step was the combination of the 
two, even though the action was somewhat less effective. To the pelvic 
band of the traction brace a lateral thoracic bar was attached reaching 
upward in the axillary line to a point opposite the middle of the 
scapula, where it was joined to a metal band that encircled the chest. 
like that of the Phelps brace. \Yhen this was securely fastened about 
the chest, the body and the limb were held in line by a long lateral brace; 



MI.m I I I \\l :01 S OPERATIONS. 



347 



the pelvis was supported by the pelvic band and the joint received an 
additional protection that was assured by traction and stiltings (Figs. 
99 and 100). 

This brace and another form similar in principle, in which the upright 
of the thoracic attachment is fixed posteriorly to the pelvic band, arc 
now in general use at the New York 
Hospital for Ruptured and Crippled. 
The efficiency of this brace may be 
still further increased by replacing 
the perineal bands by a metallic 
ring. This ring, which fits the upper 
extremity of the thigh closely, is 
attached to the upright at an inclina- 
tion corresponding to the line of the 
groin. 

It is a better support because it 
prevents antero-posterior motion 
within the pelvic band, which the 
perineal straps allow\ The ring 
may be used as the only support or 
it may be combined with a perineal 
band on the opposite side. This is 
of advantage if there is a tendency 
toward adduction. 

The apparatus is most satisfac- 
tory when the hollow upright of the 
Taylor brace is used. This is light 
and strong and is provided with an 
arrangement for effective traction, 
but in hospital practice the upright 
is made of solid metal, and the trac- 
tion is adjusted by simple straps. 
The metallic ring, besides providing 

better fixation, is a firm support that cannot be disturbed by the patient. 
It is, of course, more difficult of adjustment, and it is not suited to the 
treatment of young children because of the difficulty in keeping it clean 
and dry. 

The Thomas ring was first applied to a hip splint by Phelps (Fig. 
101), who has always urged the advantages of fixation and traction, and 




Fig 99. — The Long Inexpensive Brace 
with Solid Upright showing the 
Perineal Bands and the Adhesive 
Plaster, as used in Hospital Prac- 
tice. — (Whitman.) 



348 



POSTOPERATIVE TREATMENT. 



his brace, of which that last described is simply a slight modification, 
is supplied with an arrangement for lateral traction. Practically speak- 
ing, this is a tape by which the lower third of the thigh is held in appo- 
sition to the upright. It hardly seems possible that appreciable lateral 
traction can be exerted on the joint by this means, and certainly none 
whatever if the metallic ring is properly fitted to the thigh. The simple 
straps do not afford as effective traction as the rack and pinion, nor 
is the brace, as usually constructed, sufficiently strong to bear the 
weight of the body without bending. It should be stated, however, 
that this form of brace is intended to be used with crutches rather than 
as a walking appliance. 

Many objections to this attempt to combine the two methods of 
treatment in one appliance have been urged by those who believe in 




Fig. ioo. — The Long Hip Splint Applied. — (Whitman.) 



the efficiency of the traction brace. For example, it is said that the 
splinting is ineffective because the movements of the trunk are trans- 
mitted to the joint, while this is not true of braces that do not extend 
above the pelvis. In reply, it may be stated that the traction part of 
the combined splint remains as effective as before; thus it follows that 
this suggestion is an acknowledgment of the fact that the theory of 
motion without friction is no longer tenable. As a matter of fact, 
however, it will be found that motion of the upper part of the trunk 
is absorbed, as it were, in the flexible lumbar region of the spine, before 
it reaches the joint. If, however, such motion or any motion causes 
discomfort or aggravates the symptoms, the patient should be confined 
in the recumbent posture until the acute phase of the disease is passed. 
It is said that the brace is cumbersome, that the patient cannot sit 
with comfort, and that it prevents normal activity. A long brace 
certainly weighs more than a short one, and if a brace prevents flexion 



M1SIT1 I Willi S OIMK \ IIOXS. 



349 



at the hip and spine, it is evident that the patient cannot sit with com- 
fort in an ordinary chair. As a matter of fact, the patients themselves 
make little complaint of the brace, even when it has been substituted 





Fig. ioi. — The Long Brace with Thomas 
Ring and Extension Upright, Similar 
to Phelps Brace. — (Whitman.) 



Fig. 102. — Rear View of Brace. — (Whit- 
man.) 



for an ordinary traction splint; while the greater restraint of activity 
is a favorable element of treatment, since children who do not suffer 
pain are much more likely to be too active than to be restrained by 



35° 



POSTOPERATIVE TREATMENT. 



any form of appliance. These objections are trivial, if one is convinced 
that the dangerous and deforming disease that is under treatment 
may be more easily controlled and that the final result is likely to be 
better and to be more rapidly attained by this means than by another. 
This form of brace is used exactly as in the ordinary traction brace. 
If deformity be present, it is reduced by one or another of the methods 





Fig. 103. — Phelps Hip Splint. 



Fig. 



104. 



-A Chair to be Used with the 
Long Hip Splint. 
The patient sits upon the sound side, while the 
splinted half of the body remains in the ex- 
tended position, the brace resting on the 
floor. — {Whitman.) 



that have been described. If the disease be acute, recumbency and 
traction are employed until this stage is passed. When ambulation 
is resumed, crutches may be employed for a time, but during the greater 
part of the treatment the brace is used as a walking appliance ; as accurate 
splinting and as effective traction being employed during this period 
as circumstance will permit. During the entire course of treatment, 
supervision of the patient, with the aim of adapting his activity to the 
local weakness, should be exercised, even though it may be less essential 
than when other apparatus is employed. 



CHPATER XV. 

MODERN TREATMENT OF COMPOUND 
FRACTURES. 



CHAPTER XV. 
MODERN TREATMENT OF COMPOUND FRACTURES. 

Methods Advocated by Nicholas Senn. — The modern antiseptic 
treatment must vary according to the nature of the wound arid the 
manner in which it was inflicted. As a general rule, it may be stated 
that the first dressing decides the fate of the patient, and determines 
the process of wound healing. The treatment of the wound is of far 
greater consequence than that of the fracture itself, more especially 
during the first two weeks. A combination of most thorough antiseptic 
treatment of the former, immediate and perfect reduction of the latter, 
followed by fixation of the fractured limb by some kind of plastic splint, 
yields the best results. Whenever there is any prospect of obtaining 
primary healing of the wound, the attempt should be most faithfully 
made. In punctured and gunshot fractures and when the wound is 
small and clean-cut, the surrounding skin for a distance of several 
inches should be shaved and thoroughly disinfected by scrubbing with 
hot water and potash soap, then with alcohol, and lastly with a 5 per- 
cent carbolic acid or a 1:1000 mercuric chlorid solution. If the bone 
projects from the wound, the part protruding should be included in the 
disinfection before reduction is made, as otherwise infection may be 
caused by the reduction. Such fractures must never be explored, and 
the wound should not be enlarged unless reduction is impossible with- 
out so doing or complications present themselves that demand it. . Re- 
section of the projecting fragment is seldom necessary, as reduction can 
usually be effected under the influence of an anesthetic. It is in cases 
of this kind and in gunshot fractures that, as a rule, the wound beneath 
the skin is aseptic. Suturing of such wounds should be avoided. 

The wound, properly disinfected, is dressed by applying an anti- 
septic occlusion dressing. For this purpose nothing is more efficient 
than a nonirritating effective antiseptic powder, composed of four parts 
of boric acid to one part of salicylic acid, and a compress of aseptic 
absorbent cotton. Cotton is preferable to gauze, as it serves as a more 
efficient filter, and with the powder and blood is soon converted into 
23 353 



354 POSTOPERATIVE TREATMENT. 

a dry crust that seals the wound hermetically and excludes it from 
the entrance of pathogenic microbes. About a teaspoonful of the 
borosalicylic powder is placed on the wound, and the cotton compress 
is applied and retained with a gauze roller, or, if there is any danger 
of it becoming displaced, it is fastened in place with a strip of adhesive 
plaster before the bandage is applied. The dressing should not be 
disturbed until the Avound is healed, unless signs and symptoms indicate 
the existence of infection. Should infection follow this treatment, 
removal of the dressing, enlargement of the wound, counteropenings, 
efficient tubular drainage, energetic secondary disinfection, and sub- 
stitution of the hot antiseptic compress for the dry dressing is the proper 
course to pursue. If wound infection does not occur, the compound 
fracture is practically converted at once into a simple subcutaneous 
fracture, and should be treated as such. 

P. Bruns recommends for similar cases a powder composed of — 

Carbolic acid, 25 parts. 

Colophonium, 60 " 

Stearin, 13 " 

Precipitated carbonate of lime, 700 " 

Senn further says: "I have, however, used the borosalicylic powder, 
in the proportion specified, on an extensive scale, both in civil and 
military practice, and have been so much gratified with the results that 
I can recommend is most emphatically as a local application in such 
cases, used in the manner described. 

"In lacerated and contused wounds the first and most impor- 
tant duty in rendering first aid is to subject the wound to an absolutely 
efficient and safe primary disinfection. This can be done only by 
first shaving and disinfecting the part of the limb that is the seat of the 
fracture, and, if the fracture is near a joint, as much of the adjacent 
part of the limb or trunk as will be covered by the large antiseptic 
dressing. A common error made in the management of such cases is 
that the surface disinfection is not extended far enough. If the wound 
disinfection cannot be made with sufficient thoroughness without the 
use of an anesthetic, it is preferable to anesthetize the patient rather 
than neglect meeting, to the fullest extent, the most important indica- 
tions in the treatment of the wound. All such wounds must be regarded 
and treated as infected wounds. In most instances the wound is larger 
underneath the skin than on the surface, and a thorough primary 
disinfection is out of question without enlarging the external wound 



MODERN lKl \l\li\r OF COMPOUND FRACTURES. 355 

sufl&ciently to expose every nook and corner for the direct application 
oi the antiseptic solution. After free exposure of the wound surface 
the surgeon removes blood-clots, foreign bodies, and loose fragments 
not required in a satisfactory process of repair. If on hand, hydrogen 
dioxid should now be poured into the wound; if not, antiseptic irrigation 
with a hot 2.5 percent carbolic acid solution or a solution of mercuric 
chlorid, 1:1000, should at once be commenced and continued until the 
wound is surgically clean. I have more faith in carbolic acid than in 
mercuric chlorid as a disinfecting agent in the treatment of accidental 
wounds, as it penetrates the tissues more deeply and leaves them in a 
more favorable condition for the healing of the wound by primary 
intention. In extensive lacerated wounds it is advisable to cut away 
the torn margins, converting the wound as nearly as possible into an 
incised wound, better adapted for successful suturing. The deeper 
portions of the wound can be treated in the same manner if they are 
covered with torn tissue that would be in the way of primary union, 
for the purpose of preparing the surfaces for buried sutures, which can 
often be employed to advantage in diminishing the size of the wound 
and the space requiring drainage. The buried suture, of aseptic catgut, 
is of special value in suturing vascular tissue over the detached frag- 
ments if the fracture is a comminuted one. The disinfection must 
extend to the seat of fracture. All the loose fragments should be removed, 
disinfected in the carbolic acid solution, and immersed in a warm 
saline solution, ready for reimplantation after the wound has been 
disinfected. 

" Counteropenings for drainage may become necessary if the 
wound is irregular, and dead spaces cannot be avoided by buried sutures. 
Tubular drains well fenestrated must be employed for this purpose. 
The counteropenings are made by tunneling the soft tissues from the 
side of the wound with a pair of locked hemostatic forceps, which are 
pushed in the desired direction until the skin over the point of the instru- 
ment is raised in the form of a cone, which is then incised at its base on 
one side, and the instrument made to emerge from the wound ; the drain 
is grasped and brought into the wound with the return of the forceps. 
The tube should not project further into the wound than the cavity 
it is intended to drain. In large wounds multiple counteropenings 
may become necessary. For this special purpose the drains should 
never be thinner than the little finger, and should not be disturbed until 
the time for infection to take place has elapsed — that is, for from forty- 



;;: POSTOPERATIVE TREATMENT. 

eight to seventy-two hours. The wound itself must never be entirely 
closed by suturing, as drainage is always required in such cases, and 
must be maintained until all danger from infection has passed. The 
wound is drained, in preference, with a single strip of iodoform gai 
the projecting end of which is secured by a large, aseptic safety-pin. 
Two ways present themselves for dressing the woimd: (i) with the 
dry dressing; : with the moist dressing. The surgeon must discrimi- 
nate carefully in making the selection. The typical dry absorbent 
antiseptic gauze dressing is indicated in wounds that, from their - 
from the time that has elapsed from the receipt of the injur}' to the first 
dressing, and from the thoroughness with which the primary disinfection 
was made, we have reason to expect will heal by primary intention. In 
applying such a dressing a few layers of iodoform gauze should be placed 
next to the wound, the bulk of the dressing being made of sterile gai 
and over and around it a thick cushion of absorbent cotton should be 
placed. The dressing should be a copious one, and should be retained 
in place by a gauze roller. So copious a dressing exerts an equable 
. tic ressure, so important an element in securing muscular 
and in holding in accurate and uninterrupted contact the wound 

- . Aft : r the dressing has been applied and the fractured bone placed 
in proper position, a fixation splint of some kind should be applied over 
the wound dressing. In case no infection sets in, the first dressing may 
remain in place for two or three weeks. Should the dressing become 

rated with blood, the surface may be sprinkled with borosalicylic 
powder, and an additional layer of cotton be applied, to make an : 
change of dressing unnecessary. Xothing is more harmful in the treat- 
ment of a compound fracture than meddlesome surge :he long 

ing can remain with impunity, the gre atei is :he probability of 
avoiding infection, and the better are the chances of obtaining primary 
healing of the wound." 

The after-treatment of a compound fracture by the surgeon 
cannot be too carefully watched. He look for 

evidences of infection. A rise in temperature during the first twenty-four 
hours Hy means ferment intoxication: after that time it suggests 

ion. In fermentation fever the subjective symptoms are 
generally nil; in se] > they correspond in intensity with the degree of 
intoxication. The condition of the tongue is of more diagnostic impor- 
tance than the character and frequency of the pulse in discriminating 
between fever and sepsis. I: rrua the tongue is dry and usually 



MODERN rREATMENT OF COMPOUND FRACTURES. 357 

brown; in fermentation fever it is moist and coated. If, from the local 
and general symptoms, it becomes apparent that the wound has become 
infected, no time must be lost in removing the dressing and in making 
additional provision for drainage. Secondary disinfection is generally 

incomplete and unsatisfactory. If the wound has been sutured, every 
stitch must be removed and drainage established wherever it appears 
necessary. The moist antiseptic compress must invariably take the 
place of the dry dressing, and frequent antiseptic flushings become 
indispensable. It is advisable, under such circumstances, to replace 
the more energetic antiseptic solutions, such as carbolic acid and mer- 
curic chlorid, by Thiersch's solution or a saturated solution of the acetate 
of aluminium, as the former, used in large quantitcs and at short intervals, 
might, and often do, result in intoxication that may prove disastrous 
and even fatal. 

The antiseptic irrigation should be preceded by the injection 
of hydrogen dioxid. If suppuration does not yield promptly to this 
treatment, continuous irrigation with either of the mild antiseptic solu- 
tions must be instituted at once, and has often, in my experience, been 
the means of averting death from sepsis and in preventing the necessity 
of a secondary amputation. Should this treatment not make a prompt 
impression by improving the local conditions and by ameliorating the 
general symptoms, the propriety of performing a secondary amputation 
must be considered, with a view to preventing death from septicopyemia. 

Continuous irrigation by means of the thermal irrigator as described 
in Fig. 105 should be used, or in the absence of this apparatus a simple 
yet effective irrigator may be arranged in the following manner: A 
piece of rubber tubing, six or eight feet in length, can be used as a 
siphon, or may be connected with an opening on one side near the 
bottom of the reservoir holding the antiseptic solution, and with one of the 
drains in the wound. A stop-cock or clothes-pin is used to regulate 
the size and force of the stream. The solution must be kept at a tem- 
perature of blood-heat, or, still better, a little higher, and if more than 
one drain is employed, the point of irrigation is changed at certain 
intervals from one to the other. If many drains have been used, it 
is advisable to connect them with several siphon tubes so as to flush 
the different parts of the wound continuously. By suspending the 
limb, properly immobilized, and placing underneath it a rubber sheet, 
the fluid is drained into a vessel by the side of the bed. A compress 
saturated with the same solution is made to cover the wound and is 



358 



POSTOPERATIVE TREATMENT. 




Fig. 105. — Thermal Irrigator Stand. 

This furnishes means for irrigating with warm solutions, without the necessity of filling 
the bottles with hot fluids. The outfit consists of two irrigating bottles, mounted on a 
strong upright frame, supplied with heavy, rubber-covered casters. The bottles are ad- 
justable to various heights as required. A tank with lamp is provided, the former con- 
taining a coil of sufficient length to allow fluid passing through it to become heated to 
the proper temperature. With a Yolkmann dropping-tube for continuous wound irriga- 
tion, it makes an ideal irrigator. 






MODKRN IRKATMKNT ()V COMPOUND FRACTURES. 359 

to be changed several times a day. The general treatment in such 
cases musl In- stimulating and tonic, supported by a concentrated 

and nutritious diet. Should an adjacent joint become involved, free 
drainage and continuous irrigation constitute the proper local treat- 
ment. Progressive phlegmonous inflammation calls for free drainage 
and frequent or continuous irrigation. 

It is in cases of this kind that signal benefit lias been derived from 
applying a compress saturated with a 1:1000 solution of either the 
lactate or the citrate of silver. If a secondary amputation becomes 
necessary, the operation must be performed through healthy tissue, 
at a safe distance from the infected territory. 

Comminuted Compound Fracture of the Skull. — The mistake 
is frequently made of not removing a sufficient amount of the fractured 
bone. Spicules left even where the periosteum is adherent frequently 
inflame and cause a thickness or callus which may later cause pressure 
at the seat of the fracture. Every step of the procedure must be done 
under strict aseptic precautions. Before the wound is touched the 
whole scalp, or a large portion at least, should be carefully shaved and 
the surface of the wound thoroughly disinfected. The trephine is 
rarely needed. Senn recommends that all loose fragments removed 
should be placed in a warm 2.5 percent solution of carbolic acid for 
disinfection, reimplanting them carefully after the wound disinfection 
has been completed. Depressed fragments are elevated with the utmost 
care to preserve their vascular connection, and if the brain has been 
exposed or injured, subdural drainage is always necessary. 

After the wound has been rendered surgically clean, if it is thought 
best to replace the loose fragments, they are transferred from the car- 
bolized solution into a warm solution of salt, prior to their being placed 
upon the surface of the dura. If the fragments are large, Senn con- 
siders it advisable to fragment them with bone forceps, and reduce 
them to the size of the thumb-nail or smaller. The fragments are then 
conveyed from the salt solution to the surface of the dura with dissect- 
ing forceps, and are planted in such a manner that the smooth surface 
comes in contact with the dura. After placing them in position, the 
pericranium and skin are sutured over so as to secure for the bone- 
chips vascular tissue on both sides. Drainage is established through 
a counteropening in the scalp some distance from the fracture. 

Dry iodoform gauze dressings are applied and held in place by a 
roller bandage. If the wound remains aseptic, the fragments will 



;6o 



POSTOPERATIVE TREATMENT. 



recover their vitality, and the continuity of the skull will be restored. 
Should the wound become infected, all the sutures must be removed, 
the wound opened wider, and all the loose fragments removed. Another 
attempt may be made to render them aseptic by resorting to a vigor- 
ous secondary disinfection with hydrogen peroxid, 2.^, percent carbolic 
acid solution, or a 1 percent solution of formalin. 

Open treatment and the substitution of warm antiseptic moist com- 
presses in place of dry dressings constitute the appropriate after-treat- 
ment. 

Compound Fractures of the Leg. — After thorough disinfection of 
the wound and limb and proper fixation of the bones, the limb must 




Fig. 106. — Fracture Box. — (Breicer.) 



be placed in a suitable splint in order to secure immobilization and 
prevent displacement of the fragments, even when attempts at direct 
fixation have been made. Tenotomy is often necessary and frequently 
aids materially in the after-treatment of the more serious cases. Regard- 
ing this procedure, Dennis writes as follows: "Several years ago the 
author called attention to tenotomy in the treatment of compound 
fractures, and in a number of cases since then he has been impressed 
with the value of the operation in all oblique compound fractures, as 
well as in many simple fractures. Tenotomy relieves at once any 
contraction of the muscles, permits the fragments to be placed in accurate 
coaptation, and secures physiologic rest to the fracture. It affords 
also great comfort to the patient, and is a valuable means of fixation 
during the first ten days. Tenotomy may be employed upon the 
tendo-Acliillis, upon the hamstring muscles, upon the tendons of the 



MODERN rREATMENT OF COMPOUND FRACTURES. 



361 



arm and forearm, and even upon the sternomastoid muscle in fractures 
oi the clavicle." 

The swelling following a compound fracture is usually far more 
extensive than after simple fractures, hence it is frequently a matter 
oi great importance to adjust a splint or external fixation dressing that 
will make, allowance for subsequent swelling, and that need not be 
removed or disturbed in order to inspect or redress the wound. In 
fractures of the leg the author still employs the "fracture box of our 
fathers" as being the safest and most comfortable temporary splint 
that can be used. 

For compound fractures of the thigh a modified Buck's extension 
apparatus answers every purpose, and later, when all acute symptoms 
have subsided, a plaster-of-Paris splint (von Esmarch) may be safely 
applied. 




FlG I07 .— Modified Buck's Extension Apparatus.— (Brewer.) 



The patient must be placed in a narrow bed with a firm hard mat- 
tress. Later, there is frequently a tendency to eversion of the foot. 
This may be corrected by pinning a strip of canton flannel along the 
inner side of the leg bandage, passing it under the leg and over the 
side-splint, where it is secured by several tacks. This suspends the 
leg, taking pressure from the heel, and causes the required inversion 

(Fig. 108). 

In fractures immediately below the lesser trochanter, the lower end 
of the upper fragment is displaced by the action of the iliopsoas muscle 
which is attached to the lesser trochanter. 

The upper fragment is rotated outward. 

The lower end of the upper fragment is flexed and abducted. 



362 POSTOPERATIVE TREATMENT. 

The action of the muscle is so powerful and the upper fragment so 
short, that the fragment cannot be replaced and held in position by 
any splint. 

The usual methods of treatment by long splints and extension always 
give union with angular deformity and faulty rotation. 

Davidson's plan of treatment is to place the long lower fragment 
in such a position that its axis will be in line with that of the upper 
fragment, and with the same amount of external rotation. 

This can be accomplished by suspension of the leg in the proper 
position in a frame by the Beely anterior molded plaster splint and 
Buck's extension (Figs. 109 and no). 

A Buck's extension is put on the leg, the knee is slightly flexed, and 




Fig. 108. — Appliance to Overcome Eversion. — (Brewer.) 

a splint is molded to the anterior part of the leg and thigh, with wicking 
soaked in plaster cream and secured with a roller bandage. 

A series of rings are incorporated into the splint for suspension of 
the limb. 

The rings should be in such a position as to get the necessary rotation 
of the lower fragment to match the faulty rotation of the small upper 
fragment when the leg is suspended. 

The leg is suspended sufficiently high to equal the flexion of the 
small upper fragment. 

The frame is attached to the outer part of the foot of the bed in such 
a position that the lower fragment will be in the axis of abduction of 
the small upper fragment. 

Sufficient weight on the Buck's extension will overcome the shorten- 



MODERN rREATMENT OV COMPOUND FRACTURES. 



3 6 ; 



When the immobilization is completed, the reduction of the fracture 
ihould be verified by the flouroscope. 




corg 

50 



Immobilization of fracture, by means of sutures, wire, ivory 
pins, nails, bone ferrules, screws, etc., cannot be relied upon exclusively. 
A suitable external splint is therefore needed. In applying any splint 



364 



POSTOPERATIVE TREATMENT. 



or retention device, the soft parts should be protected, especially near 
and over the seat of injury, and in the neighborhood of the bony promi- 
nences, by cotton pads, or preferably sheet-wadding. Care should 
be taken to avoid undue pressure, and a portion of the limb below 
the seat of the injury should always be left exposed to enable the surgeon 
to watch the condition of the circulation. In all cases in which extensive 
contusions, edema, or ecchymoses exist, the dressings should be removed 
and the parts inspected frequently until all danger of strangulation, 
sloughing, or gangrene has passed. 

In all compound fractures, when the swelling and inflammation 




Fig. 1 10. — Posterior View of Suspended Limb. 



have in a great measure disappeared, the limb should be placed in a 
more fixed or permanent dressing. The fenestrated plaster cast or 
wire splint, allowing free access to the wound and drainage openings, 
will be found most useful and hasten resolution by enforcing rest. 

To apply an encircling plaster cast to a member, the limb should be 
held firmly in position by assistants. A thin layer of lint or lintine should 
first be evenly applied to the- part, after which several layers of sheet- 
wadding should be placed carefully around the limb. This is more 
easily applied if made into rollers. After the limb is evenly covered 



MODI R\ rREATMENT OV COMPOUND FRACTURES. 



36S 



by this material, several rollers of crinolin impregnated with plaster- 
of Paris should be placed in warm water to which a teaspoonful of salt 




" < 

Z « 
o < 

I g 

X 

W 

Q 
Z 

< 



has been added. A plaster roller should then be applied to the limb, 
covering the parts evenly with from four to six layers of the plaster- 
holding material. Where a light cast is desirable, thin strips of splint- 



3 66 



POSTOPERATIVE TREATMENT. 



wood may be inserted between the layers and less plaster applied. 
(Brewer.) 

A window should be left or subsequently cut in the plaster, freely 
exposing the wounded area, which can then be dressed without removing 
the supporting cast (Fig. 112). 

The cast is usually allowed to remain from five to seven weeks, at 
which time it should be removed and the limb carefully inspected. If at 
this time the external wound is entirely healed and the fracture shows 
evidence of union, an ambulatory splint may now be adjusted, which 
will admit of greater freedom and be more comfortable to the patient. 

Massage of the entire limb should now be employed, and later passive 
motion of the knee-joint and ankle-joint should occasionally be made 
until recovery is complete. 

After-care of Compound Fracture of the Arm at or near the 
Elbow. — The treatment of compound fracture of the arm is practically the 
same as compound fracture occurring at any other point, so far as 
the fixation or adjustment of the bones is concerned, but where injuries 




Fig. 112. — Plaster Cast with Wound Exposed. — (Stimson.) 

occur near the elbow, the reapplying of splints and apparatus should be 
done sufficiently often to discover undue swelling or pressure upon the 
arm. All apparatus should be removed at least once a week and care- 
fully inspected during this interval. In most instances it will be wise 
to delay passive motion until firm union of the bones takes place, seldom 
before the sixth to the eighth week, and even then must be very gently 
performed. Massage to the hand, wrist, forearm, elbow, and upper 
arm after the external wound has healed and the swelling has begun to 
subside, is of great value. The removal of the splint should be tentative 
and gradual after the union is known to be firm. (Scudder.) 



MODERN IRK ATMK.xr OF COMPOUND FRACTURES. 367 

The arm should be held in a sling for an hour and then the splint 
applied. The following day a longer Interval is granted without the 
splint, and gradually the splint is removed entirely. 

A snugly fitting bandage will often prove comfortable as a support 
on first leaving off the splint. Passive motion, massage, and active use 
of the arm will now assist in regaining the use of the joint. At this 
stage the carrying of dumb-bells, pails or baskets filled with sand, and 
the doing of certain gymnastic movements with the injured arm will 
be of material aid. All violent exercise of the part is to be avoided. 
That amount of exercise may be alknved which leaves the arm moder- 
ately tired. 

These patients should be kept under observation for at least four 
months. It is wise to treat such cases until all that can be achieved 
toward a restoration of function has been accomplished. (Scudder.) 

After-treatment and Progress of Fracture of the Thigh. — Inspec- 
tion of the fractured limb should be made at least daily. Measure- 
ment should be made twice a week during the first few weeks, the internal 
malleolus being reached through the bandage. Parts of the apparatus 
may need changing, and straps may require tightening or loosening. 
The heel and sacrum will require attention because of the constant 
pressure from lying in one position. 

Ordinarily, there will be little or no pain associated with the repair 
of the fracture. After about four w^eeks all apparatus should be removed 
and the limb thoroughly inspected, to detect, if possible, any uncorrected 
deformity, and to determine whether union is yet firm. In from four to 
six weeks repair in a healthy child or young adult should have been 
advanced to the stage of firm union. The apparatus should then be 
reapplied. At the end of the eighth w^eek all apparatus should be 
finally removed. The thigh should be washed and thoroughly oiled. 
The patient should be permitted to lie in any position in bed without 
retentive apparatus for one week. After the splints are first left off and 
while the patient is still in bed daily systematic massage to the whole 
limb should be practised, together with slight passive and active motion 
at the knee-joint. The patient should not be allowed to bear weight 
upon the unprotected thigh until after the ninth week. At the end of 
the- ninth week he should be alknved up and about with crutches, and 
a moderately high-soled shoe (tw r o inches) should be worn upon the foot 
of the uninjured thigh. He should bear no weight upon the injured 
leg. The seat of the fracture should be protected by coaptation splints 



368 



POSTOPERATIVE TREATMENT. 



and straps and a light spica plaster-of- Paris bandage from the toes to 
above the waist. At the end of twelve weeks all support may be dis- 
carded. Of course, fractures of the femur vary considerably in the 
time the patient is able to get about, but the foregoing routine is that of 




Fig. 113. — Ambulatory Splint Applied. 



Fig. 114. — Patient Walking with Ambulatory 
Splint. 



average uncomplicated cases. Some surgeons, however, would discard 
all apparatus and get the patient up and out of bed, on crutches, within 
a shorter time than here indicated, but if error is committed it is infin- 
itely wiser to err on the side of safety. It is very probable that massage 



MOPKRN rKKATMENT OF COMPOUND FRACTURES. 



369 



D 




H 



without any passive motion, as early as the second week, to the region of 
the knee and thigh, will prevent much of the knee-joint disability and 
muscular atrophy that so often hinder convalescence in these cases. 
It is very important also, in order to gain this end, to see that the exten- 
sion is made from around and above the condyles of the femur, and not, 
as so often happens from the knee-joint itself. 

In the ambulatory treatment of fracture of the thigh by means 
of an ambulatory splint a high sole upon the shoe worn on the well 
foot, and crutches, are of very great value, especially in children and 
young adults. The hip splint, consisting of a long outside upright, 
with pelvic, thigh and calf bands, is applied with 
two perineal straps (see Figs. 113 and 114). The 
traction is made through the windlass at the foot- 
piece after fastening the extension strips to it. The 
countertraction is made by the two perineal straps. 
The thigh is securely held by coaptation splints and 
a bandage about the thigh and splint. The patient 
goes about with crutches and a high sole of two 
inches upon the shoe worn on the well foot, bearing 
a little weight upon the foot of the splint. As a 
matter of fact, the real value of this method in 
fracture of the thigh lies in the improvement to the 
general health by the early getting into the upright 
position and out of bed. This application of the 
ambulatory method certainly is of great comfort to 
the patient. That it hastens the reparative process 
is yet to be fully demonstrated. If the hip splint is 
used, it should be applied when union is found to be 
firm. After wearing the splint in bed for a few 
days the patient may get up and about. 

Fracture of the Thigh in Childhood (Scudder). — This is usually 
caused by direct violence. The fracture is often incomplete. The 
symptoms are those of the same fracture in the adult. The effusion 
into the knee-joint is seen perhaps more uniformly than in the adult. 
This effusion disappears from the child's knee-joint more quickly than 
from the adult knee-joint. 

Treatment. — After reducing the fracture — making the incomplete 
fracture complete if perfect reduction cannot be accomplished in any 
other way — the problem of maintaining the reduction arises. In 
24 



F E 

"ABO 

Wire Splint for 
Fracture of the 
Hip and Thigh. 
— {Scudder.) 



37o 



POSTOPERATIVE TREATMENT. 



children of ten years and older it is possible to use Buck's extension. A 
plaster-of- Paris spica splint from the calf of the leg to the axilla is also a 
possible method of immobilization. 

In children under ten years of age the Cabot posterior wire frame 




Fig. i i 6. — The Cabot Wire Splint Ready for Use. 
Lateral view, showing curves of splint corresponding to small of back, buttock, and 

knee. — (Scudder.) 




Fig. 117. — The Cabot Wire Splint Ready for Use. 

Front view, showing covering of canton flannel and canton-flannel double swathe for 

fixation to chest. — (Scudder.) 



with coaptation splints and extension is the very best method of con- 
veniently and efficiently treating a fractured thigh or fractured hip. 
The Cabot posterior splint consists of two portions — a body 



MOniRN IRI \IMI\r OF l'().MI'Or\I) FRACTURES. 



371 



pari and a leg part. The patient lies upon the body part with the thigh 
and leg resting upon the leg part, as upon a coaptation splint. Having 
a vise and simple iron wire the size of an ordinary lead-pencil, this 
splint can be made in a few moments; the bending of the wire according 
to the diagram and fastening the free ends by a strip of small-sized wire 
being all that is required. It is necessary to make the following measure- 
ments before bending the wire to the general shape shown in the diagram 
— namely, D E, the distance from the axilla to the calf of the leg; A D, 
the width of the trunk; A B, from the axilla to a point midway between 
the crest of the ilium and the top of the great trochanter; F E, the width 
of the leg, usually from two to two and a half inches. A D and B C are 
bent to the curve of the back. B C is so bent that it jumps over the 
sacrum and does not touch posteriorly excepting at B and C. The long 
rods are so bent as to adapt them to the posterior curve of the buttock, 
thigh, popliteal space, and leg (see Figs. 115, 116). 

The splint is covered, as in the posterior wire splint for the leg, by 




Fig. 118. — Bradford Bed-frame for Fixation of Trunk in Fracture of the 

Thigh. — (Scudder.) 



layers of sheet- wadding and cotton bandages. A swathe is attached to 
the two sides A B and D H of the body part (see Fig. 115). The child 
is carefully laid upon this splint, the body swathes adjusted, the extension 
strips applied, traction made by weight and pulley with the foot of the 
bed elevated, coaptation splints applied and held in position by straps 
that include the posterior wire splint. If it is necessary to move the 
child for the making of the bed, for the use of the bedpan, or for 
bathing, the extension may be unfastened temporarily without any 
injury to the fracture, particularly if the coaptation splints are then 
temporarily tightened to secure a firmer hold on the thigh. The child 
should be, of course, clean from both urine and feces, and the fracture 
immobilized. 

After four weeks of bed-treatment the child may be up, with crutches 
and a high shoe with the Cabot splint applied. Shoulder straps should 
be attached to the splint when it is worn in the erect position. This is 



37 2 



POSTOPERATIVE TREATMENT. 



one of the simplest, cleanest, and most efficient methods of treating 
fracture of the thigh in young children. The child can be moved with 
freedom and without pain. A light plaster-of-Paris spica bandage may 
be used in convalescence with crutches and a high shoe on the unin- 
jured side. 

In very small children it is sometimes wise to use the Bradford (see 
Fig. 118) frame and vertical suspension (see Fig. 119) of one or both 
thighs. This is an efficient, comfortable, and clean method of treat- 
ment. The Bradford frame is an iron, frame-like stretcher, on which 
the child lies and to which the shoulders and hips are fastened to prevent 




Fig. 119. — Fracture of Thigh in a Child. 

Bradford frame. Vertical suspension of leg with weight and pulley. 

to thigh and fixation of pelvis by towel swathe about frame.- 



Coaptation splints 
-(Scudder.) 



the child's moving about. Counterextension is then secured by the 
immobilization of the pelvis and hip. The extension is applied to the 
thigh and leg as usual. The limb is flexed on the body to a right angle, 
coaptation splints being applied to the thigh. After the novelty of the 
position passes away, the child is perfectly contented. As soon as 
union is firm, the permanent plaster spica dressing may be applied, 
and the patient may be up and about with a high shoe on the well 
foot and with crutches. The use of the long hip splint will be of great 
service in these cases either with or without the extension foot-piece 
(see Figs. 113, 114). After fracture of the shaft of the femur in children 



MODERN TK1 \ 1MI AT OF COMPOUND FRACTURES. 373 

there should be DO shortening and no especial difficulty in convalescence. 
It is wise to guard the thigh a sufficient time after union is firm to insure 
absolute solidity and freedom from bowing in any direction. 

Complications during and after repair of fractures form a most 
interesting subject for observation and study. The complete usefulness 
of a limb is not fully restored as soon as the fracture has been repaired. 
During the process of repair, as well as after union is complete, it is 
possible for many complications to arise and require special treatment. 

Surgical Emphysema is a condition that is often encountered in 
the management of fractures. This consists of the entrance of atmos- 
pheric air into the meshes of the connective tissue, and is termed "sur- 
gical emphysema," to distinguish it from emphysema of the lung. 
The source of the infiltration of the air into the connective tissue may be 
from injury of the lung in fracture of the rib, in which case the emphy- 
sema has been observed to reach to the scrotum, and at times it may 
spread over the face so that the patient is unrecognizable. The air may 
escape to such an extent as seriously to embarrass respiration. Another 
source of emphysema may be from the generation of gases as a result of 
putrefactive changes or of the growth of gas-producing bacilli in the 
tissues. There are only a few cases observed of emphysema in simple 
fractures; the majority of the cases have been complications in com- 
pound fractures. Or the gas may escape from a wound in the intestine, 
or even from the air-sinuses in the bones of the face and skull. 

If the emphysema arises from injury to the lung, no interference is 
indicated unless the emphysema is so extensive as to produce dyspnea, 
in w r hich case free incisions can be made or the air allowed to escape 
through a trocar. The air is usually absorbed in a few weeks, and 
produces no harm, since it has been filtered in its passage through the 
lungs, and is therefore not likely to set up inflammation. In case the 
condition arises from putrefactive changes, the application of the 
principles of antiseptic surgery is required. 

Edema consists of the infiltration of serous fluid into the interstices 
of the areolar tissue, and, unless it is due to some organic disease of the 
liver, kidney, or heart, is the result of too tight bandaging or the sudden 
removal of the splint, or, finally, of obliteration of the large veins from 
thrombosis. If due to local causes, the edema usually disappears after 
the removal of the cause, or, if to a loss of support of the vessels by the 
removal of the splint, the edema rapidly subsides as soon as the function 
of the limb is restored. Placing the limb under a faucet and douching 



374 POSTOPERATIVE TREATMENT. 

it alternately with hot and cold water will stimulate the circulation; 
and this treatment, aided by massage of the muscles when the patient 
begins to walk, will relieve the condition. 

Delirium tremens and traumatic delirium are two complica- 
tions that frequently occur. The differential diagnosis is often difficult 
to make, but the tremor in the limbs and an alcoholic history occurring 
soon after the receipt of injury, with absence of fever, point to the former 
as contrasted with the latter condition. In both forms of delirium the 
patient has delusions, mutters incoherently, is often violent and excitable, 
and has a dry, tremulous tongue accompanied by free diaphoresis. 

Treatment consists in placing the fracture at once in a plaster-of- 
Paris splint or fixed dressing, and watching the patient carefully, even 
to the extent of employing a special attendant. If the delirium becomes 
too active and it is impossible to restrain the patient, a strait- jacket 
must be employed. If the patient is robust and young, liquor can be 
withheld; but if aged and feeble, it is necessary to continue stimulants 
with judgment. The bromids, chloral, hyoscyamus, and in some cases 
morphin, are the remedies which have proved the most successful. In 
organic disease of the kidney morphin is apt to cause suppression of 
urine, and must be employed with caution. The diet must be nutritious 
and abundant, and the patient's strength maintained. 

It should not be forgotten that acute septicemia with rapid rise of 
temperature may cause delirium closely resembling that of trauma. 
Therefore, in the after-treatment of compound fractures, should delirium 
later supervene, the wound must be carefully examined for local signs 
of infection and treated accordingly. 

Pneumonia is a complication likely to arise during the repair of a 
fracture. It is especially likely to occur in alcoholic patients with com- 
pound fractures, and forms a most serious complication. The treat- 
ment of the disease is conducted upon the same principles that govern 
the physician in a case of traumatic pneumonia (see page 48). 

Osteomyelitis is a form of suppuration in bone, and is caused by 
the presence of septic micrococci in the wound. It is therefore most 
likely to occur in compound fractures, although the disease in the form 
of acute abscess may occur after any traumatism of bone. The osteo- 
myelitis sets up necrosis of bone, and the patient may die from septic 
infection before the sequestrum can be removed. Septic emboli may 
start from the thrombi, and metastatic abscesses develop. The treat- 
ment of this condition consists in freely exposing the seat of the abscess 



MOOKRN IKi: ATMKNT OV COMPOUND FRACTURES. 375 

and trephining the bone above it, if necessary, in order to reach the 
disease and establish free drainage, after which the wound is treated as 
heretofore described under "Septic Wounds." 

Fat-embolism was first fully described by Wagner and Zenker. 
Pat-embolism means the entrance of fluid fat from the medulla of the 
bone into the veins in the immediate vicinity of the fracture, and through 
these channels into the capillaries of the brain, spinal cord, lungs, 
kidneys, and other essential organs. The presence of fluid fat in the 
blood was described in 1836 by R. W. Smith, but the clinical importance 
of this condition was not recognized until recently through the investiga- 
tions of von Bergmann, Czerny, and Scriba. Dejerine has experi- 
mentally produced fat-embolism in the lower animals by inserting 
laminaria tents into the medullary cavity of the bone. The symptoms 
of fat-embolism appear on from the third to the fifth day, as a rule, and 
resemble those of secondary shock. They occur before the time at 
which venous thrombosis or pulmonary embolism would be expected to 
appear. Great dyspnea, associated with the Cheyne-Stokes respiration, 
irregularity of the heart's action, and a sudden rise of temperature, to- 
gether with twitching of the muscles, as well as paralysis of certain 
muscles, have been observed in these cases, and also fat-globules are 
found in the urine. There have been no metastatic abscesses discovered 
where an autopsy has been made. This group of symptoms must not 
be mistaken for shock following fracture nor for pulmonary embolism. 
Shock may be said to be present three hours after the fracture, fat- 
embolism three days after, and pulmonary embolism three weeks after. 
For convenience these complications have been arranged in the order 
in which they are most likely to occur, and by associating these conditions, 
which simulate each other, with the time at which they appear, no 
mistake in diagnosis is likely to arise. 

The treatment of fat-embolism consists in the administration of 
ether in the form of some such preparation as Hoffmann's anodyne, or 
even by hypodermatic injection. In case of great dyspnea venesection 
has been suggested, and also artificial respiration. The pulmonary 
edema must be relieved by cardiac stimulants and by cupping. The 
fracture should be kept perfectly quiet, lest any movement of the frag- 
ments might cause further absorption of the fat by disintegrating the 
medulla of the bone. In case there are great comminution of bone and 
disintegration of the medulla, amputation may be immediately indicated 
as a life-saving expedient. 



376 POSTOPERATIVE TREATMENT. 

Gangrene of the limb may occur either as a result of mechanical 
or traumatic causes or from septic infection. Gangrene arising from 
mechanical causes is due to the application of too tight a splint or band- 
age or to the improper and prolonged use of a tourniquet. The gangrene 
resulting from traumatic causes is due to a crushing or laceration of 
the soft structures near the fracture, or else to the rupture of the main 
vessels by the same agency which produced the fracture, or by the sharp 
fragments of bone, or, finally, to pressure from hemorrhage or from an 
unreduced fragment. The occurrence of gangrene in the treatment 
of fractures often leads to suit for malpractice. It is therefore important 
for the surgeon to define clearly the causes over which he has control, 
and those which are beyond his control, such as contusion, laceration 
of bloodvessels or nerves, pressure of a fragment of bone, or the oblitera- 
tion of the lumen of the artery from thrombosis due to senile changes 
or calcification of the artery, and the presence of diabetes, with which 
gangrene is so often associated, especially after an injury. 

The treatment must depend upon the cause, extent, and the general 
condition of the patient. In small, localized areas of gangrene measures 
should be adopted to encourage the separation of the slough, while in 
gangrene with a line of demarcation forming, amputation can be resorted 
to when the healthy and dead tissues are clearly defined. In case of 
rapidly spreading gangrene, with symptoms of serious septic intoxication, 
amputation high above the gangrene should be immediately performed. 

Pyemia and septicemia are conditions which arise in the course 
of the repair of a fracture, and for a full description of these complica- 
tions the reader is referred to the article devoted to a consideration of 
this subject. 

Thrombosis is a complication that under rare circumstances occurs. 
When a vein has been wounded a clot forms which closes the vessel. 
From this thrombosis an embolus may travel to the lung, where it may 
occasion death by plugging the pulmonary artery. This complication 
occurs without any warning, usually about three weeks after the receipt 
of the fracture. The patient expires suddenly with great dyspnea, 
cyanosis, feeble pulse, and cardiac pains. It occasionally happens that 
small emboli may become detached, and produce alarming symptoms 
which gradually disappear. In all cases in which there has been oblitera- 
tion of the veins, with formation of thrombi, it is dangerous to practise 
massage early or to disturb the seat of fracture, since an embolus might 
be torn away from the thrombus and set free in the circulation. 



MODERN iki \IMK\T OF COMPOUND FRACTURES. 377 

Atrophy or mi limb following fracture is a complication that 
is likely to occur, especially when there has been long- continued dis- 
use of the limb, as in fracture of the patella. The atrophy is most 
marked in the muscles above rather than in those below the joint nearest 
to the fracture, and it is especially prone to appear in rheumatic diathe- 
sis and to involve the extensor muscles. The atrophy involves the 
connective tissue as well as the muscles, and the condition may be depend- 
ent upon an injury to the nerves in the limb, or possibly to a prolonged 
use of continuous compression. The atrophy is susceptible to treat- 
ment by gentle massage, hypodermatic injection of strychnin, sham- 
pooing of the limb, and moderate exercise. 

Paralysis of the muscles below the seat of fracture may occur 
as a complication during the repair of fracture, as a result either of 
associated injury to the nerves supplying the affected muscles, or of 
an inclusion of the nerves in an exuberant callus during the process 
of repair. In the former case the paralysis is present simultaneously 
with the occurrence of the fracture, and if the nerve is a mixed one 
there will be loss of motion and sensation. The simple tests for motion 
and sensation should be made in examining every case of fracture, since 
a paralysis which is overlooked at the time of the examination of the 
fracture may be attributed subsequently to carelessness on the part 
of the surgeon. In case paralysis is due to pressure, electric stimu- 
lation of the main nerve trunk above the callus fails to excite the muscles 
to which the nerve is supplied. 

The treatment consists in extricating, if possible, the nerve from the 
callus by means of a surgical operation, and the application of the 
constant current to the nerve until it has regained its function. 

Ankylosis of joints occurs as a complication following fracture. 
The ankylosis may be either permanent or temporary. The permanent 
variety consists of an osseous ankylosis, and the condition is a result of 
a fracture directly into the joint, so that the fragments within the joint 
have become united. For the removal of this condition surgery can 
offer no relief unless an aseptic resection of the joint is performed, and 
this operation is limited to joints like the shoulder, elbow, wrist, and 
ankle, and possibly a few others. The temporary ankylosis is the 
result of a concomitant injury which has set up an arthritis, or it may be 
due to the prolonged use of extension in the treatment of certain fractures, 
or it may be the result of hemorrhage into the joint which has excited 
a synovitis and arthritis with the formation of intraarticular bands 



378 POSTOPERATIVE TREATMENT. 

of fibrous tissue. In Colles' fracture the fingers are often stiff from a 
thecal inflammation, and it is with great difficulty that this condition 
can be relieved. 

The treatment consists in massage, shampooing, the use of hot fomen- 
tations of bran, the alternate douching with hot and cold water, and 
active movement. It should be remembered that passive motion must 
be begun early, but with the utmost care, in case a fracture invades a 
joint or is so near that the callus is likely to involve the joint. In Colles' 
fracture passive motion in the fingers should start from the first, and 
at the wrist after one week. In no ordinary case of fracture should 
passive motion be delayed more than two weeks, unless delayed union 
or nonunion is apparent. 

Necrosis of bone occurs as a complication during the repair of frac- 
ture, and is due to the fact that the periosteum has been detached 
from the fragment or from the shaft of the bone. In the former case 
the loose fragment should be removed at the time of the reduction and 
first dressing; in the latter case the superficial scale of bone undergoes 
necrosis, owing to its diminished vascular supply. Generally a sinus 
leads down to the exfoliated bone. This tract should be excised and 
the bone removed, as a long- continued sinus discharging ichorous 
pus is a condition favorable to the development of an epithelioma. 

The causes of nonunion in bones after fracture are constitutional 
and local. Among the constitutional causes, in which the reparative 
action is impaired or misdirected, may be mentioned old age and certain 
constitutional diseases, as fevers, syphilis, scurvy, malignant disease 
of bone, and rickets. Paralysis may also be a cause, as is illustrated 
by a case of spinal injury with fracture of the humerus and leg of the 
same side, in which the arm united, but the leg failed to unite. 

iVmong the local causes of nonunion may be mentioned the direc- 
tion of the line of fracture, since oblique fractures are more frequently 
attended by failure of union than transverse or impacted. Among the 
other causes may be found separation of the fragments, the interposi- 
tion of foreign bodies, muscle, tendon, or fascia, between the ends of 
the broken bones, or suppuration, profuse hemorrhage, the continued 
use of wet dressings, and, finally, improper dressings, in which the 
splints are either too tight or too loose. The rupture of the main nutrient 
artery at the time of fracture may result in nonunion. 

The treatment of nonunion of bone following fracture is to be con- 
sidered from a constitutional as well as a local point of view. It is 



MODERN IRi \TMK\T OF COMPOUND FRACTURES. 379 

the combination oi general and local treatment that is most apt to 
bring about the desired object. In every case a careful inquiry should 
be made in regard to certain so-called diatheses. The treatment of 
this condition has for its object the correction of any constitutional 
dyscrasia. A syphilitic diathesis should be treated with the full admin- 
istration of antisyphilitic remedies; a gouty or rheumatic tendency, 
by remedies suited to these special diseases; scurvy, rickets, scrofula, 
tuberculosis, and marasmus should be treated with tonics and a nutri- 
tious diet, with the aid of the best hygienic surroundings. The tonics 
best suited for those conditions in which the general health is impaired 
are iron and the phosphates. 

In conjunction with the general management the local treatment 
is to be pursued. The means employed must consist of the removal 
of any offending body between the fragments and the excitation of 
a certain amount of inflammation around the ends of the fragments. 
The local treatment must 
further consist in the applica- 
tion of an immovable splint 
specially adapted to the ex- 
igencies of the case. 

The operations which have 

been devised with a view to 

~ . , Fig. 120. — H. H. Smith's Splint for Un- 

effecting union m ununited united Fracture of Leg.— (Dennis.) 

fracture are multifarious. 

They all have one common object — viz., the excitation of inflammation; 
but many of the old operations are at the present time abandoned as a 
result of the introduction of antiseptic surgery. The use of the seton, 
the injection of irritating fluids, the cauterization of the fragments, the 
application of blisters and of caustic alkalis to the skin over the site of 
the ununited fracture, the introduction of electric currents, the violent 
percussion with the mallet — are among the various operations which are 
practically discarded as unsuitable, and in their places modern surgery 
has instituted a number of aseptic operations, for description of which 
the reader is referred to works of general surgery. 

Fracture of the Patella. — Fractures of the patella, whether simple 
or compound, are usually accompanied by more or less profuse swelling, 
which makes its appearance ordinarily within three or four hours 
following the receipt of the injury, the swelling being due to the accu- 
mulation of blood and synovial fluid in the knee-joint. Before any 




3 8o 



POSTOPERATIVE TREATMENT. 



method is resorted to with a view to bringing the fragments into apposi- 
tion, the surgeon must endeavor to control and modify the joint inflam- 
mation. The ice-basr is used with great benefit durinsr the first dav or 
two, after which lead-water and laudanum wash may be used. So 
soon as the inflammation and swelling have subsided, uniform pressure 
by means of an elastic bandage will hasten absorption of the fluid. 
The limb can be so placed by slightly elevating the leg that the position 
alone will afford an excellent method of treatment. The limb may 
be elevated and placed upon a well-padded Hamilton splint, or an 
ordinary inclined plane splint (see Fig. 121), so that the foot is from 




Fig. 121. — Inclined Plane Splint. — {Dennis.) 



one to two feet above the foot of the bed, and in this way the rectus, 
crureus, and vasti are relaxed, and there will be no traction upon the 
upper fragment. Xo operative measures should be attempted until 
the inflammatory action has subsided, unless the fracture is compound, 
when the operation of fixation of fragments should be performed. 

There are two methods of treating fracture of the patella — one is 
called the expectant plan, and the other the operative treatment. In 
the expectant plan or method of treatment the lower fragment is fixed 
by means of adhesive straps or other appliances placed obliquely about 
the leg and splint, and fastened to the splint above the fragment, either 
a ham-splint, an Agnew splint, or a Cabot posterior wire splint having 
first been adjusted to the posterior surface of the limb. 

Treatment by ttte Expectant or Xonoperative Method. — 
During the first four weeks fixation of the knee, elastic compression, 
douching, massage, the thigh flexed slightly on pelvis, the leg extended, 
retentive straps, coaptation splints, are the measures employed. At 
the fourth or sixth week remove all apparatus, apply removable splint, 
allow walking with crutches, and use daily passive motion. At the 
eighth week discard crutches, use cane, and permit limited daily active 
motion. At the sixth month discard splint, apply flannel bandage, 



MODERN 1KI -\r\ll\r OF COMPOUND FRACTURES. 



381 



and discard cane. At the eighth to the tenth month remove all support" 
(Scuddcr.) 

The operative treatment consists in the reduction and fixation 
of the fragments which are held in place by wire or animal sutures, 
after which the limb, in an extended position, is immobilized by some 
fixed dressing. If the operation is performed with aseptic precaution, 
the drainage may be removed on the second or third day. 

Postoperative Treatment. — At the end of about four or six weeks 
from the injury union will be found. The retentive straps and coap- 
tation splints should now be removed, and the leg immobilized by a 
plaster-of-Paris splint extending from below the calf of the leg to the 
groin. Fixation (prevention of flexion and extension) on walking is 
to be maintained for at least six months after the injury. Protecting 
the knee thus when walking for this period of six months does not pre- 
clude active movements of the knee when not bearing weight upon the 




111 i)j 1 1 . y^jtaiijjiijiiiiiijijfc 

Fig. 122. — Agxew's Splint Applied. — (Dennis.) 



limb. At the end of that time the patient may be allowed to go about 
with a cane and a snugly fitting roller bandage. This bandage should 
be made of medium weight flannel, cut straight with the weave and 
not on the bias. The bandage should be applied from the middle of 
the calf of the leg to the middle of the thigh when the leg is completely 
extended. As the patient becomes confident of his strength, . the cane 
need not be carried. Sudden movements are to be avoided. At the 
end of eight or ten months, varying with the individual case, all support 
may be omitted from the knee. 

The Restoration of the Function of the Joint. — From the day 
of the injury daily massage to the whole limb is important. It main- 
tains the muscles in good tone. It prevents adhesion of the fragments 
to the tissues about the condyles of the femur, a not uncommon cause 
of ankylosis of the joint. It facilitates the absorption of the effusion 



382 POSTOPERATIVE TREATMENT. 

of blood and synovial fluid. After the fourth week daily passive motion 
is to be instituted — at first very slight indeed, barely two or three degrees. 
If the relative position of the fragments is not altered perceptibly by 
this passive motion and lasting pain is absent, it may be persisted with 
in regularly increasing amounts. At the expiration of eight or ten 
weeks active motion at the knee-joint may cautiously be allowed. The 
appearance of persistent and increasing tenderness, sensitiveness, or 
pain, and increasing separation of the fragments are the indications to 
diminish or cease passive and active motion. 

SHORTENING FOLLOWING FRACTURES OF LONG BONES. 

Shortening must, to a limited degree, follow all fractures of long bones. 
The age and condition of the patient at the time of the receipt of the 
injur}-, the condition of his blood, rheumatism, etc., are important factors 
not under the control of the surgeon but which play a very important 
part in postoperation shortening. I wish, however, to call particular 
attention to the fact that patients are discharged entirely too soon and, 
while they may become restless and impatient at their prolonged con- 
finement, nevertheless they should not be allowed to return home or pass 
from observation until a firm bony union has occurred. I have person- 
ally examined 42 cases of fractures of the femur, occurring in patients 
ranging from 23 to 54 years of age, the examination being made from 
4 to 12 years following the injury; 7 of these cases occurring in 
my own practice, and, in fact, all the cases examined had complete 
hospital records, and showed positively no shortening at the time of 
their discharge. The average time of detention in the hospital of 
these 42 patients, of which we have positive records,, was 12 weeks, the 
longest 18 weeks, and the shortest 8 weeks. In but five of these cases 
was the function or usefulness of the limb absolutely unimpaired. The 
shortening was found in every instance varying from one-half to two and 
five-eighth inches. In all of these cases, before leaving the hospital, a heavy 
spica bandage or some external support had been applied and worn from 
two to six weeks by the patients. Shortening therefore followed although 
all ordinary precautions were taken to prevent it, occurring after the patient 
had passed from the observation of the attendant. In reference to 
the time required for fractures of the femur to unite, Scudder and others 
say as follows: "After the eighth or tenth week the splints should be 
removed and the patient be permitted to lie in any position in bed with- 



MODERN IK 1 ■WTMKNT OF COMPOUND FRACTURES. 



383 



out retentive apparatus for one week Longer. After the splints are first 
left oi\ and while the patient is still in bed, daily systematic massage to 
the whole limb should be practised, together with slight passive and 
active motion at the knee-joint. The patient should not be allowed 




Fig. 123. — Showing Postoperative Shortening. 



to bear weight upon the unprotected thigh until after the ninth week. 
At the ninth week he should be allowed up and about with crutches. He 
should bear no weight upon the injured leg. The seat of the fracture 
should be protected by coaptation splints and straps or a light spica 



3^4 



POSTOPERATIVE TREATMENT. 



plaster-of-Paris bandage be applied. At the end of 12 weeks all support 
may be discarded." (Scudder on " Fractures.") The foregoing routine 
is that of uncomplicated cases, and is the practice now generally adopted 
and taught by leading surgeons. I believe it a mistake to say that even or- 
dinary fractures of the femur or of the tibia and fibula should be expected 
to be firmly united in that length of time. In fact, no patient should 




J 



Fig. 124. — X-ray Photo of Fracture of Thigh. 



be permitted to leave the hospital or to return home except at his own 
risk, before 16 to 20 weeks, and I am satisfied that, could these fractures 
of the leg and thigh be kept sufficiently long under the daily observation 
of the attending surgeon, the record of shortening would be greatly 
reduced if not wholly prevented thereby. The following skiagraphs 



MODERN TREATMENT OF COMPOUND FRACTURES. 385 

and history will tend to illustrate the author's position on this much 
neglected subject. 

H. S., conductor on railroad, was thrown from a car and sustained a slightly 
oblique fracture of femur at upper third. Eight weeks following the receipt 
of the injury the patient was allowed to go to his home. A sole leather sup- 
port and bandages were applied and the patient provided with crutches. Be- 
fore being discharged from the hospital a careful measurement of the limb 
was taken by two or three competent men, who agreed there was practically 
no shortening and the measurements were made a matter of hospital record. 
One year following the injury a skiagraph was taken of the limb, which by 
measurement was found to be 3 inches short and revealed the fact that the 
lower end of the femur was pushed upward and rested on the trochanter. 
See Fig. 123. 

A firm bony union had certainly not taken place and had this man 
remained under daily observation of the attending surgeon four or eight 
weeks longer, or until the bones could have been more firmly united, no dis- 
placement or shortening could have occurred. 

Fig. 124 is a skiagraph of a fracture of the femur taken fourteen years 
after the injury. According to the hospital record there was no percep- 
tible shortening at the time of his discharge. He remained in the 
hospital ten weeks. The patient states that he never discovered any 
difference for three or four months following the fracture, at present the 
limb is one and three-eighth inches short. 

Fractures of the tibia and fibula are especially liable to shorten- 
ing after a fair degree of union occurs, if the unsupported leg is used 
too soon or too much. 

Comminuted and oblique fractures are always longer in uniting and 
give rise to more trouble after repair than a simple transverse fracture. 

Complications following the too early use of the limb after a fracture 
are: deformity of the leg, flat-foot, shortening, limited motion of the 
knee- or ankle-joint, rheumatism, weakness of the leg, swelling of the 
leg or foot, and nocturnal cramps. Before discharging the patient, 
therefore, as a matter of safety to the attendant surgeon and for future 
reference a careful skiagraph should be taken, which will disclose whether 
or not the bone has firmly united, and should the patient insist on 
leaving the hospital or care of the attending surgeon, he should be made 
to understand that he must do so whollv at his own risk. 



25 



CHAPTER XVI. 
AMPUTATIONS. 



CHAPTER XVI. 
AMPUTATIONS. 

General Remarks. — Modern surgery seeks not only to insure healing 
by first intention in an amputation, as in every other operation, but 
also to leave a functionally useful stump. A stump, to be functionally 
useful, must be capable not only of bearing weight and pressure, but also 
of movement. But in satisfying these demands we only fulfil part of 
our endeavors. The first essential for the usefulness of a stump is free- 
dom from pain; the second good nutrition, so as to prevent atrophy of 
the muscles and bone. 

If in recent times we have obtained more useful stumps than formerly, 
we are indebted, in the first place, to asepsis. Smooth and painless 
cicatrices can only be got when the wound heals accurately and without 
infection, for it is the thick, dense cicatrices resulting from an inflamma- 
tory condition of the wound that are painful. The worst of all, however, 
are the irregular hypertrophic inflammatory scars with overgrowth of bone. 
For this reason, as well as because of the dangers of infection and the 
discomforts of delayed union, we should do all in our power to insure 
healing by first intention. (Kocher.) 

We shall not here again consider the treatment of wounds, but we 
may refer the reader to the chapter on the subject at the beginning 
of the book. We would again point out, however, how important it is 
that clean incisions should be made whose edges can be accurately 
fitted together. Numerous experiments under the direction of Tavel 
have clearly proved that lacerated and irregularly torn wounds are much 
more prone to be infected by a definite number of organisms than are 
those which are cleanly cut. Consequently, as absolute freedom from 
germs in the wounds which we make cannot at present be attained, 
the chances are that a clean and properly conducted amputation will 
heal without reaction, while one in which the technic is poor will sup- 
purate. Thorough arrest of hemorrhage and proper drainage always 
help to insure a good cicatrix. 

But even though we avoid infection and escape a hypertrophic, need- 
lessly thick, dense cicatrix, every stump is not a serviceable one. The 

389 



39° POSTOPERATIVE TREATMENT. 

cicatrix even of a wound which has healed by first intention will remain 
sensitive if it is exposed to special mechanical injuries, such as traction, 
or pressure, conditions met in cicatrices on the trunk which are injured 
by the movements of the body and the pressure of clothes. Pressure 
and traction are to be avoided, especially when an artificial limb has to 
be worn. 

The cicatrix is exposed to most pressure if it lies between the bone 
and the artificial limb or any external object. The muscles and ten- 
dons inserted into the cicatrix exert most traction on it if it is fixed to an 
immobile structure, especially to the bone. To avoid painful pressure 
the scar should, therefore, not lie under the end of the bony stump in 
any case in which it is to be utilized to bear weight or pressure. The 
only incisions which meet this indication are the oblique incisions and 
their modifications, as illustrated above. It is only by dividing the soft 
parts deeper on one side than the other that one can get a cicatrix placed 
where no pressure can be exerted on it. 

It should be noted that this applies not only to the skin, but also to 
the deeper soft parts, the fascia, muscles, tendons, and periosteum. 

These layers must also be divided obliquely if the scar is not to lie 
on the pressure surface. We grant that scars vary in sensitiveness, 
those of muscle being less sensitive than those of skin; but, again, a 
scar in periosteum behaves quite differently, because of the great sen- 
sitiveness of this membrane, which, moreover, is easily stimulated to 
permanent proliferative changes by mechanical irritation. It has 
already been noted that the cicatrices on the ends of nerves (the most 
sensitive parts of all) are best kept out of the region of the stump by 
division of the nerve higher up. 

Therefore, the united surfaces of the soft deeper parts (including 
the periosteum) should not be situated directly over the end of the stump. 
This is a point which up till now has not been specially attended to in 
the periosteoplastic method. But even although the operation be 
properly performed by means of the oblique method, there still remains 
a possible source of pain in the stump, dependent on the shape of the 
bone. If sharp corners and edges are allowed to remain, which are 
driven into the soft parts by the weight of the body, there will always 
be a painful stump. Fortunately this is less likely to occur if the scar 
does not lie under the bone. It has been rightly pointed out that in 
Syme's amputation of the foot a stump capable of bearing the weight 
of the body is provided if the malleoli are not sawed off. This can only 



\mim rATiONS. 391 

be obtained if one distributes the pressure on the less prominent bony 
pan-. No one would be able to walk if supported only on the apex 
oi the most prominent point, the external malleolus. 

In the face of this fact it can be easily understood why, by the older 
methods, we so often got serviceable stumps at the epiphysis (as Hirsch 
has shown, but for a different reason) and so rarely in the shaft of a 
bone. The epiphysis can easily be rounded off, and this should always 
be done, so that the pressure from below may be distributed equally 
over a large surface. We maintain expressly that by this means painless 
and very useful stumps may be obtained in amputations above the mal- 
leoli and through the condyles of the femur without any osteoplastic opera- 
tion, provided care be taken that the soft parts covering the stump are 
movable and do not contain a scar. 

In the case of the shaft of a bone it is extremely difficult to attain this 
rounding off. We have to do here with a tube with a hard exterior; 
and if we do roimd it off, we simply transfer the edges from the outer 
surface of the bone to the medullary surface. But the main point is 
that a really well-rounded stump in the shaft is technically very difficult 
to get. We have not yet got sufficient evidence as to how far a carefully 
rounded section through the shaft, which is covered with scarless" peri- 
osteum and scarless soft parts, is really adapted to bear weight without 
giving pain. 

Hirsch must be recognized as having called attention to the fact that 
stumps which have been stripped of periosteum are quite useful. In 
his method, as in the most ancient methods, Hirsch does not preserve 
the periosteum. He makes no osteoplastic nor even a periosteoplastic 
covering, but leaves the end of the bone bare of periosteum, and it is 
interesting to learn that at the Surgical Congress in Berlin, 1901, his 
method found eloquent supporters. Bunge, from Eiselberg's clinic, 
declares that it is injurious to cover the stump with the sensitive perios- 
teum, and that, on the contrary, it should be removed, as the stump 
will then be much more useful, because less sensitive. On the same 
grounds Bunge scrapes out the medulla, so that this sensitive part may 
not be pressed upon. 

Bier is convinced that it is harmful to operate subperiosteally, be- 
cause of the resulting overgrowth of bone. But as he prefers the osteo- 
plastic to the older methods, it follows that it does not signify much 
whether the periosteum is removed, or whether it is replaced over the 
sawed surface. The point is that a good stump may be formed in vari- 



39 2 POSTOPERATIVE TREATMENT. 

ous ways,, provided the end of the bone is rounded, broad, and smooth 
and has no corners or edges to exert pressure on sensitive parts. But 
another point which has been too long neglected is that it is essential 
that the stump should retain the good shape given to it at the operation. 

For if one wishes to prevent injurious growth from the medulla or 
from the bone itself, the stump must be subjected as early as possible in 
the functional relationships to which it will later be exposed. The 
irregular overgrowths which are sometimes described will then not 
occur, because functional activity determines the direction of cicatriza- 
tion. 

If the wound heals rapidly by first intention, strong and serviceable 
stumps can be assured, be they aperiosteal, subperiosteal, or osteoplastic, 
by taking care that the skin- cicatrix, the fascial scar, the stump of the 
nerves, and the muscle-cicatrix are away from the seat of pressure. 
This can be effected by the oblique oval method of incision, by making 
the end of the bone broad and round, by causing it to press against por- 
tions of muscle and skin which are only slightly sensitive, and by accus- 
toming it early and carefully to gradually increased pressure. The best 
stumps are always those in which the skin and periosteum covering the 
face of the bone retain their normal relationship to each other, as in 
Bier's or PirogofFs osteoplastic operation, especially if the skin is already 
accustomed to pressure, as in Gritti's operation and Ktister's modi- 
fication of PirogofFs amputation. 

Besides the necessity of preventing pressure on the scar, we must direct 
attention to the necessity of preserving the scar from traction. The scar 
is pulled on by the movements of a stump only if it cannot follow those 
movements, and this especially happens if it is adherent to the firm resist- 
ing bone. 

If. therefore, in addition to the normally adherent periosteum, the 
normally movable soft parts, especially the sensitive skin, become adher- 
ent to the sawed surface of the bone, pain will naturally occur on move- 
ment. But if one covers the sawed surface with periosteum, retaining 
its normal relation to the soft parts, adhesion of the latter in the course 
of cicatrization is prevented. As already seen, this adhesion happens 
only when one has separated the soft parts from their normal relation to 
the flap of periosteum. In this lies the chief value of the periosteo- 
plastic method, and to a considerable extent of the osteoplastic method. 
The latter is preferable to the former in all cases in which the shaft is 
divided, because it makes it easier to obtain a rounded-off stump. The 



AMPUTATIONS. 393 

Layer of bone which is applied to the sawed shaft does not require always 
to have a very regular surface as long as it has no sharp corners or edges. 

Bier has called attention to the necessity of accustoming a stump to 
pressure early, and using it soon, so as to prevent atrophy of the bone 
and soft parts. Atrophic stumps are sensitive, just as are atrophic 
limbs on which no operation has been performed. But it is of equal 
importance that the growth of the end of the bone should be prevented 
from forming projecting angles, and thus interfering with the functions 
of the stump. It is because there is so little danger of exostoses and 
hyperostoses forming on the end of a bone when the amputation has 
been done by Hirsch's aperiosteal method that the stumps are so efficient 
in bearing weight. Bier's requirement, therefore, applies especially 
to periosteoplastic stumps, but also to all stumps in which primary 
union gives opportunity for early use. 

The principle of preventing hypertrophy of scars, pressure and traction 
on a scar, and atrophy of the soft parts, allows us to formulate the follow- 
ing: 

Procedure for a normal operation : An oblique incision (combined, 
if necessary, wdth a longitudinal one in the form of a racket or lanceolate 
incision, E, F, G, Fig. 125) through skin and fascia. After retracting 
the elastic skin the muscles are divided obliquely down to the bone. 
The periosteum is also to be divided obliquely. The periosteum is 
then separated, along with the superficial layer of the cortex of the bone, 
by means of a sharp raspatory or chisel, or, when possible, a flap of bone 
having a movable periosteal hinge is made by means of the saw; lastly, 
if only a thin shell of the cortex has been raised up along with the per-' 
iosteum, the end of the bone is simply rounded off, while if a distant 
flap of bone (osteoplastic method) has been sawed up, the end of the 
bone must be sawed in a curved direction so as to fit it. The periosteal 
or bony flap is sutured over the sawed surface of the bone to its periosteum. 
The stumps of the muscles or tendons are sutured to each other or to 
the surface of the bone at a distance from the sawed surface. Lastly, 
the skin and fascia are sutured. But in cases in which a periosteal 
flap, or a flap of bone and periosteum, cannot be obtained in normal 
relation to the other soft parts, it is better to remove the periosteum en- 
tirely from the end of the stump, to scrape out the medullary cavity 
(according to Eiselberg and Bunge), and to round off the edges of the 
bone as dentists do. 

American surgeons, as a rule, now pay very little attention to the hard 



394 



POSTOPERATIVE TREATMENT. 




Fig. 125. — Illustrates Various Methods of Amputation. 

A, Circular amputation of thigh; a, saw line; B, amputation by equal flaps; b, saw line; 
D, posterior incision for disarticulation of hip; C, racket incision; E F and FG, racket 
incision of flap with circular method for muscles and bones; H, amputation of hip, 
equal flap method; K, Stephen Smith amputation at knee. 



AMPUTATIONS. 395 

and fixed linos formerly laid down by surgical guidance in amputations. 
The paticular method of amputation adopted for any given case now 
depends not upon the surgeon's predilection for any one form of incision 
or kind of flap, but upon the actual condition of the parts; thus in rail- 
road injuries or amputations following injuries the main idea in the sur- 
geon's mind is how to insure the best stump that shall be as useful as 
possible. Not only will he save all that is possible of the limb, but will 
often shape his flaps in an irregular manner so as to obtain a longer and 
more useful stump. By the proper employment of antiseptics, inflam- 
mation and sloughing of the stump have been greatly diminished, 
while the danger of secondary hemorrhage has practically disappeared. 
It is now possible to fashion flaps from tissues that have been bruised by 
injury if their vitality has not been markedly interfered w 7 ith, which here- 
tofore it was not thought possible to save. 

Another noticeable feature in present-day methods is the increase- 
ingly frequent use of skin-flaps and the diminution in the amount of 
muscle employed to cover the bone. (Cheyne-Burghard.) 

While it is well to be intimately acquainted with all the typical methods 
of amputation suitable for different situations, it is of extreme practical 
importance for the surgeon to remember that he can modify any of these 
to meet the varying circumstances of any individual case, and that he 
may use lateral, oblique, or irregular flaps according to the nature of 
the case wdth which he is dealing, so long as he is thereby .enabled to 
provide a satisfactory stump without sacrificing more of the limb than 
is absolutely necessary. While no doubt the set operations may be 
followed to advantage in aseptic cases or for diseased conditions, the 
patient's interests are better served in the majority of cases in which the 
surgeon is nowadays called upon to amputate, by some irregular form 
of amputation than by one on old-fashioned lines (Fig. 126). 

There are tw r o methods employed which affect materially the after- 
care or postoperative treatment, namely, the closed and open methods, 
the former being applicable to all aseptic cases, the latter, chiefly to 
railroad injuries or septic cases. 

All cases require the ordinary aseptic precautions, such as shaving, 
scrubbing thoroughly, and disinfection of the field of operation. The 
entire limb except the field of operation should be carefully wrapped 
in disinfected towels which should be fixed in position by safety-pins 
or a roller bandage. After the arteries have been ligated with double 
catgut ligatures, and all hemorrhage or oozing checked, preferably by 



396 



POSTOPERATIVE TREATMENT. 




Fig. 126. 

A, Amputation of thigh, long anterior and short posterior flap; H, anterior incision for 
disarticulation of hip, anterior and posterior flap; B, disarticulation of knee, elliptic 
incision (Bauden's operation); C D, Lee's amputation of the leg; T T, Teale's amputa- 
tion of leg; P, Guyon's supramalleolar amputation. 



win i aiions. 



397 



hot normal salt irrigation, after the insertion of a small drainage-tube 
at the most dependent portion, the muscles may be brought in appo- 
sition by means of catgut sutures and the skin-flaps closed with silk- 
worm-gut and fine horsehair sutures. 

Dressings. — The ordinary iodoform, xeroform, or cyanid gauze 
dressings may now be applied. Care should be taken to have a suffi- 
ciently large amount to cover the parts thoroughly. Over this is placed 
a layer of sterile absorbent cotton, and, lastly, plain sterile gauze, over 




Fig. 127. — Author's Method of Dressing after Amputation. 

Illustrates manner of applying fixed bandage over the rubber tissue or jaconet. The 
rubber tissue is then folded back, exposing the stump, and protects the fixed bandages. 
The exposed stump is then ready for the dressing and a second bandage is applied. 



which a careful bandage should be applied with some degree of firm- 
ness to obviate the spasmodic jerking of the muscles of the stump. 
This latter is also obviated, with much comfort to the patient, by apply- 
ing a splint to the remaining portion of the amputated limb. 

After aseptic amputations it is our custom to make the first change 
of dressing the sixth or eighth day following the operation, when the 
drainage-tubes may be withdrawn. The wound should be again dressed 
as before with several layers of gauze, cotton, etc., and remain undis- 



398 



POSTOPERATIVE TREATMENT. 



turbed for six to eight days. By the end of this time, or the fourteenth 
day, the silkworm-gut sutures may be removed, and if there is no evidence 
of infection, narrow strips of sterile adhesive straps may now be applied 
with sufficient firmness to mold or give the proper shape to the stump. 
Over these maybe placed layers of antiseptic dressings, and a snug band- 
age applied. 

In the second class of amputations, in which more or less sepsis is 
unavoidable, after all oozing has been controlled, one or two stitches 




Fig. 128. — Shows the Rubber Tissue Folded Back over the Fixed Bandage, 
Ready for the Dressings. 

The fixed bandage not only affords a good hand-hold, but 'prevents relaxation of the 
muscles and enables the temporary dressings to be removed with little disturbance or 
pain to the patient. 



of silkworm-gut may be taken at either angle of the wound, the center 
of the wound being left open. It is now carefully but gently packed 
with iodoform gauze down to and well covering the end of the bone. 
If it be a leg or thigh amputation, it is our custom before applying the 
dressing to cover the limb with sterilized guttapercha tissue (see Fig. 
127) leaving it extended over the wound five or six inches (see Fig. 128). 
We then apply our permanent bandage, commencing four or five inches 



AMPUTATIONS. 399 

from the line of amputation, placing the bandage well back over the limb 
as high up as necessary, and securing this with safety-pins. The gutta- 
percha extending over the amputated part is now folded back over the 
permanent bandage. We now apply several layers of iodoform gauze 
over and around the open stump. Over this are placed absorbent cot- 
ton and sterile gauze, and, lastly, a bandage is placed as snugly as possi- 
ble over the dressings and extended back over the other or primary band- 
age. The primary or supporting bandage holds the tissues snugly to- 
gether and furnishes a hand-hold and enables the other dressings to be 
removed with less annoyance and pain to the patient. 

Ajter-treatment oj Septic Cases. — The dressings should be changed 
on the day following the operation, as there is usually a considerable 
amount of oozing during the first twenty-four hours. The frequency 
with which the dressings require changing subsequently will depend 
upon the amount of discharge. No attempt should be made to remove 
the gauze drainage from the wound before the fourth to the sixth day 
and only such as becomes loosened should be removed. From the 
sixth to the eighth day the entire gauze drain will become loosened and 
should be removed, the wound being again gently packed. 

Healing of the wound is generally rapid, so that by the eighth to the 
fourteenth day the wound may be drawn together by means of sterile 
adhesive straps. The straps are applied with the object of shaping 
or molding the stump and to guard against too wide separation of the 
flaps. If the suppuration has been excessive, irrigation with Thiersch's 
solution may be necessary, but ordinarily it is best to avoid any form 
of irrigation or moisture, the wound being kept clean by wiping it care- 
fully with gauze sponges dipped in hot normal salt solution, and after 
drying the stump as carefully as possible, a dusting-powder of zinc 
stearate may be used and will greatly facilitate healing. 

Amputation of the thigh or leg by the closed method requires four- 
teen to twenty-one days to heal. When the open method is employed, 
three to six weeks are usually required before patients can be discharged. 

Faulty Stumps. — Postoperative Complications. — A stump may 
be faulty from either of three conditions: namely, (i) adhesions of the 
cicatrix to the end of the bone, (2) involvement of sensitive nerves in 
the scar tissue, or (3) from a formation of what is called conical stumps. 

Should the scar become adherent to the bone, there is often great 
pain on pressure. This may occur even though the larger nerves have 
been cut short, and is then due to the implication in the cicatrix of the 



4-00 POSTOPERATIVE TREATMENT. 

smaller nerve branches which may become bulbous and give rise to 
excessive pain. (Cheyne.) 

Quite apart from the neurotic condition of the stump in which the 
cicatrix is adherent, there is usually persistent and often spreading 
ulceration in the scar, owing to the low vitality of the cicatricial tissue, 
which later breaks down upon the slightest pressure. This may leave 
a granulating surface very difficult to heal. In stumps of this kind the 
nutrition of the entire end of the stump is defective. It is cold, livid 
in color, and is very liable to be affected by low forms of inflammation 
and obstinate ulceration, or the faulty nutrition may give rise to eczema, 
in which case there will be a sticky, watery discharge. These cases 
are frequently very obstinate and in the end may call for a reamputation. 

Treatment. — In all cases of adherent cicatrix much time and useless 
suffering on the part of the patient may be saved by reamputation, and 
a far better result is obtained by performing an entirely fresh amputation 
and fashioning new flaps than by simply opening up the wound and 
resecting a portion of the bone. If such a partial operation is done, 
the nerves are still left implicated in the cicatrix and fresh adhesions 
between the layer and the bone are very apt to occur; hence in all cases, 
except possibly in those in which a reamputation would involve the loss 
of a joint, it is better to fashion fresh flaps which do not contain any scar 
tissue. Where, however, an important joint, such as the knee-joint, 
may have to be sacrificed, if fresh flaps are to be made, or in case the 
patient objects to further amputation, recourse should be made to exfo- 
liation of the tissue by means of an ointment of resorcin, one dram to the 
ounce, followed by applications of zinc oxid, bismuth subnitrate, or cal- 
omel. If these do not suffice to heal the stump, the removal of a portion 
of the bone after opening up the old cicatrix may prove efficient. 

Conical Stumps. — The so-called conical stumps result from one 
of three causes. In the first place, the flaps may have been so badly 
planned at the time of the operation that they could be brought with 
difficulty over the end of the bone, the result being that if the muscles 
contract or slough the skin becomes more and more tightly stretched 
over the end of the bone, and the stump therefore becomes conical. 
Secondly, the condition may result from excessive sloughing or con- 
traction of the muscles after an amputation in which the flaps have 
been accurately fashioned at the time of the operation. This frequently 
occurs in muscles of subjects in whom healing by first intention has 
failed. Lastly, it is a common occurrence in young subjects in whom 



win r.vnoNS. 



401 



a perfectly successful amputation has been performed through bones 
in a condition of active growth. The stump gradually becomes more 
and more conical. As time goes on, this condition appears to depend 
on want of proper relation between the development of the* soft parts 
generally and the growth of the bone. (Cheyne.) 

Treatment. — The only rational treatment is to open the wound and 
to remove as much bone as may be necessary to make a satisfactory 
stump. The amount or extent of bone removed must, of course, vary 
with the age of the patient. An older person will not require so great 
a removal as a younger person, in whom the bone may be expected to 
stow considerably. 

Postoperative Changes Following 
Amputations. — The muscles become 
atrophied, and their divided extremities 
are found to be embedded in a mass of 
sound fibrous tissue. Those whose func- 
tions are abolished are more or less en- 
tirely converted, in process of time, into 
connective tissue. Such as retain any 
capacity for action retain to a correspond- 
ing extent some muscular structure. 

The divided bone becomes rounded off ; 
the medullary canal is closed either by 
bone or by fibrous tissue. The extremity 
becomes either atrophied and pointed, or 
presents an abnormal enlargement due to 
a development of bone from the perios- 
teum. The new bone in some stumps forms a button or mushroom- 
like extremity for the shaft. In other instances the new bone-forma- 
tions are scanty and spicular, and play the part of foreign bodies in 
the stump. 

The whole shaft of the bone w r astes. After an amputation through 
the knee the femoral condyles may entirely disappear; and in an amputa- 
tion above that joint, not only may the shaft and trochanters become 
evenly atrophied, but this retrogressive change may extend to the pelvic 
bone of the same side. After a disarticulation the cartilage left upon the 
bone atrophies and becomes fibrous, or entirely disappears in the course 
of years. 

The nerves undergo a like atrophic process. The true nerve-fibers 
26 




1 29. — Disarticulation 
the Shoulder. 
a, Oval method; b, method by del- 
toid flap. — (Dennis.) 



402 POSTOPERATIVE TREATMENT. 

disappear to a variable extent, and are replaced by connective tissue. 
This change may extend to the spinal cord and even to the nerve columns 
concerned. The divided extremities of the nerves may become enlarged 
and form considerable bulbous terminations. It may be here said, 
however, that this condition is not necessarily associated with tenderness 
of the stump. 

The collateral circulation is soon restored in the limb after the high 
division of the main artery. That trunk in time attains to such dimen- 
sions as are demanded by the vascular needs of the part. Some years 
after an amputation at the hip by an anterior flap the portion of the fem- 
oral artery left in the stump will probably be no larger than the radial. 
The wasting of the main arterial trunk may be attended by an overdevel- 
opment of certain of its branches, so that after a lapse of time the prin- 
cipal artery may be difficult to identify on dissection. 

AMPUTATION AT SHOULDER- JOINT. 

After-treatment. — A drainage-tube will be required, as a considerable 
amount of fluid commonly escapes from the synovial membrane which 
is left behind. This complication may be avoided by dissecting the 
membrane out carefully at the time of the operation. Pressure should 
be applied to the outer flap after the stitches have been introduced, in 
order that the great cavity left beneath the acromion may be, as far as 
possible, obliterated. 

The method advised by Farabeuf for the adjustment of the wound 
after Larrey's operation is very excellent. A modified Velpeau dressing 
or a Desault bandage may be applied. The median part of the wound 
is united by sutures as usual. The lower extremity is left open, to 
permit of efficient and simple drainage. The upper portion of the 
wound is not united by sutures, but the edges of the incision are brought 
together by a compress. This compress, which is applied on the outer 
aspect, not only supports the wound, but also forces the integuments 
under the acromion, and obliterates the hollow about the glenoid fossa. 
The patient's thorax should be kept raised and the body inclined a little 
toward the injured side. 

INTERSCAPULOTHORACIC AMPUTATION. 

After-treatment. — The wound, when closed with sutures, forms 
an oblique line running from above downward, outward, and backward. 
A large pocket is left in the stump, in which inflammatory exudations 



AMPUTATIONS. 4°3 

may readily collect. This pocket should be obliterated by pressure, 
a manor best accomplished by covering the wound with iodoform gauze, 
over which the pressure of a bandage is brought, or the open method of 
treatment may be employed. If this is well effected, and if no diseased 
or damaged tissue has been left behind, a drainage-tube is not required. 
The patient should be kept well raised up in bed. There is a special 
risk of pneumonia after this operation. 

AMPUTATIONS AT THE HIP-JOINT. 

After-treatment. — After the operation all necessary means should 
be taken to prevent severe shock. The head should be kept low, the 
body well covered with blankets and kept warm by a hot bottle, and, if 
necessary, enemas of brandy, or salt solution and whisky or hot coffee 
may be administered. Intravenous injection of saline solution may be 
necessary during or after the operation and strychnin may be given 
hypodermatically. 

By means of a suitable cradle the stump can be left uncovered and 
the dressings be exposed to the air. The stump should be supported 
upon a firm pillow or cushion, care being taken that no pressure is ex- 
erted upon the wound. 

If every care is taken, the great wounds left by these operations will 
heal throughout by first intention. There is always considerable dis- 
charge of serosanguinolent matter from the large wound surface. In 
the racket operations, and in Guthrie's disarticulation, drainage may be 
secured by omitting a suture or so at the most dependent point of the 
wound. In the transfixion operation by anteroposterior flaps a drainage- 
tube will most probably be required. 

As tension sometimes arises from simple extravasation of blood which 
interferes materially with healing, Senn recommends the introduction 
of an absorbable capillary drain at the lower angle of the wound. A 
strand or two of catgut twisted into a cord answers an admirable purpose, 
affording a sufficient drainage without interference with healing, and 
requires no change or interference with the dressings. 

The first dressing should be voluminous and firmly secured by an 
elastic bandage forming a figure-of-8 around the pelvis. On its inner 
and front aspect the dressing should be covered with jaconet or rubber 
tissue. It is important to defer the changing of these dressings for three 
or four days if possible, as it may increase the shock. There may be 
retention of urine, requiring the use of a soft catheter. 



404 



POSTOPERATIVE TREATMENT. 



The weight of the flaps renders it important that the sutures should 
not be removed too soon, and after their removal it will, as a rule, be 
found necessary to support the flaps by strapping. 

Care must be taken that the dressings are not soiled by urine or feces, 
and that bedsores do not form over the sacrum or the trochanter of the 
opposite side. As the action of the bowels may soil the dressings, it is 
best to keep them from acting for four or five days by a small opiate. 

Prosthetic Considerations. — The average American surgeon ampu- 
tates solely on the principle of saving "all that is possible," thus making 
in the majority of amputations a nearly hopeless case for the prosthetist, 
and in many instances leaves the crippled patient to the fate of wearing 
an artificial limb only with great inconvenience and discomfort. 




Fig. 130. — Wyeth's Amputation at Hip. — {Brewer.) 



European surgeons are far in advance in this respect, and after pro- 
longed scientific observation and experiment seem to have grasped 
the importance of operating from a functional as well as an anatomic 
standpoint, thus assisting the manufacturer of artificial devices in adding 
to the future comfort and welfare of their patients. 

Of the few American surgeons now in accord with these advanced 
ideas, Nicholas Senn is one of the most prominent. In a late surgical 
treatise in his able article on the general technic of amputations he 
writes as follows: 

"In all amputations below the base of the thigh the functional result 
must be taken into serious consideration in determining upon the site 
of the operation. Disarticulation at the knee-joint has but few advo- 
cates at the present, time because the resulting stump is bulbous and 



AMPUTATIONS. 405 

ill adapted for the wearing of an artificial limb. In amputations through 
the upper part of the leg it must not be forgotten that a stump four inches 
long is the shortest one that enables the patient to wear an artificial 
limb. It is such a stump, too, that will be most serviceable in wearing 
a peg-leg, which, among the poorer classes, is largely depended upon for 
locomotion. If an amputation has to be done above this level, the next 
point of selection is through the base of the condyles. For this operation 
the surgeon should select the Gritti-Stokes' transcondyloid osteoplastic 
amputation, which yields an ideal conic stump, well fitted for the wearing 
of an artificial limb." (Senn.) 

"Whenever admissible, in all amputations of the lower extremity 
above the ankle-joint, the operation should be made at a point and in 
such a manner as to secure a conic stump, so keenly appreciated by 
every manufacturer of artificial limbs, and subsequently by the patient. 
It must be remembered that w T hen the patient comes to wear an artificial 
limb, the w r eight of the body should not fall upon the end of the stump, 
but upon its sides, something that can be fully and satisfactorily accom- 
plished only if the shape of the stump is conic." 

"This can be illustrated also by injury or disease of the ankle-joint 
and tarsus necessitating amputation. The pathologic indications may 
be fully met by Syme's amputation through the ankle-joint, but the 
resulting stump w-ould be far less useful to the patient than if the amputa- 
tion had been made at the point of selection — that is, at the junction of 
the middle and lower third of the leg." In this connection Fred T. 
Murphy, after extended inquiry into the subsequent history of amputa- 
tion cases, says : Partial amputations of the foot or amputations of the 
ankle-joint, except under unusual conditions, are not as satisfactory as 
those above the ankle-joint. Tibial stumps between six and eight 
inches long are the most serviceable. Amputations through the knee- 
joint are inferior to those just above the condyles. The longer the 
thigh stump, the better, provided the condyles have been removed. In 
general, in tibial amputations down to four inches and in thigh amputa- 
tions down to five inches, sacrifice bone in order to obtain good muscle 
flaps. 

AMPUTATION OF THE THIGH. 

After-treatment. — The thigh should be raised and supported upon a 
firm pillow or cushion, to which it should be lightly secured. The limb 
should be placed in the adducted position. The extremity of the stump 



406 POSTOPERATIVE TREATMENT. 

should project beyond the end of the pillow. It will be thereby exempted 
from pressure, and drainage will not be interfered with. A supporting 
splint is not required in these amputations, although it may sometimes 
be employed with advantage after the circular operation and in amputa- 
tions through the lower part of the limb. 

A few sutures should be omitted at the most dependent angle of the 
wound, to allow for drainage — or, better still, a short tube and piece 
of gauze should be inserted at that situation. The oozing during the 
first twenty-four hours is considerable. In no case should a large 
drainage-tube be drawn right through the depths of the wound from 
one extremity of the incision to the other. 

As the flaps are large and heavy, the sutures should not be removed 
too soon. After their removal, the flaps may need to be supported for 
a while by strapping. 

If silk ligatures have been applied to the arteries, no attempt should 
be made to remove them prior to the fourteenth day, after which date 
at the time of the daily dressings the ligatures in turn should be gently 
pulled upon, but no harsh effort should be made to remove them. It 
frequently happens that silk ligatures will remain quite firmly embedded 
in the tissues, causing very little disturbance, for weeks or months. 
Should, however, after several weeks, a slight tenderness or sloughing 
occur, the patient should be anesthetized and the ligatures forcibly 
removed. 

AMPUTATION OF THE FINGERS AND THUMB. 

In amputating fingers the flaps should be made so that the cicatrix 
should come upon the dorsum of the hand with the least possible inter- 
ference with the palm. 

Treatment. — The wounds after these operations as a rule heal well, 
but are often very painful. As the skin of palmar flaps is usually thick 
and stiff, the sutures should be well applied, and should not be too soon 
removed. Silkworm-gut sutures are well adapted for these operations. 
The hand should be kept elevated, and never allowed to hang down, 
and care must be taken that too tight bandages are not applied about 
the wrist. 

In the larger operations, especially when a palmar flap has been cut, 
the hand should be supported upon a splint in order to arrest the move- 
ments of the wrist. As a rule, no drainage-tube is required, a small 
piece of the selvage of iodoform gauze, or a few strands of horsehair or 



WIIH IWTIONS. 



407 



of silkworm-gut, being usually all that is necessary; hut when the meta- 
carpus is concerned, and when the tissues of the palm have been lacerated 




Fig. 131. 




Fig. 132. 



408 



POSTOPERATIVE TREATMENT. 



or torn, a small tube may with benefit be introduced and retained for 
some twenty-four or forty-eight hours. It should be remembered, 
particularly in dealing with laboring-men, that to conserve every particle 
of tissue which may be of subsequent use to the patient is the highest 
art of surgical treatment. In case fingers have been severed by accident, 
we are not to sacrifice bone in order merely to secure flaps. By this 
method healing will take place more slowly, but the additional length 
of the fingers more than compensates for the delay. 

The partial operations following upon crushes of the hand must 
be treated upon the same principles as apply to complicated or contused 
wounds. 

Figs. 131 and 132 represent postoperative results in cases where the 
amputation was performed regardless of any fixed rule or special method 
and made solely with the view to preserving as much tissue as possible, 
and forming strong, useful hands. 

AMPUTATIONS OF THE TOES OR PORTIONS OF THE 

FOOT. 



Considerations of Asepsis. — It must be confessed that the wounds 
of these operations do not always heal so kindly as might be expected, 
and often compare unfavorably with like wounds 
in the hand. In a few cases this may be due to 
the fact that the operation is an imperfect one — a 
mere trimming of a mangled part — and is the out- 
come of a desire to remove as little tissue as 
possible. 

The less free circulation of the part, and the 
circumstance that the wound is less conveniently 
placed for drainage, may serve in other cases to 
explain the tardier healing when compared with 
operation wounds of the fingers. There is little 
doubt, however, that the chief reason lies in im- 
perfect disinfection of the skin before operating. 
The clefts between the toes are unrivaled breeding-grounds for bacteria. 
Before an amputation in this region the most sedulous care should be 
paid to repeated disinfection with alcoholic solution of mercury biniodid 
or of carbolic acid. If the aseptic precautions are thorough, the wound 
will probably heal as well here as in any other part of the body. 




Fig. 133. — Amputation 
of Toe. — {Hare.) 



win r \ noxs. 



409 



Removal of Sutures, Drainage, etc. — As the skin of plantar flaps 
is usually thick and stiff, sutures should be so applied as to retain a good 
hold of the parts. They should not be removed too soon, as the flap 
may give way. Silkworm-gut sutures may often be left in for ten or 
even fourteen days. The smaller amputations require ordinarily no 
drainage. In operations upon the great toe, a fine tube, or a tube 
split in halves, or strands of silkworm-gut, or a gauze drain may be 
retained for the first twenty-four hours. In case of the removal of the 
great toe, together with its metatarsal bone, 
the foot should be allowed to lie a little upon 
its inner side, provided direct pressure is not 
made upon the wound. When the fifth toe 
has been removed in a similar manner, the 
foot should be inclined toward the opposite 
side. 

Position. — The limb should be kept ex- 
posed or outside of the bed-clothes. The leg 
should lie so that the foot can rest upon one 
or the other side. When the patient lies flat 
on the back, the toes point upward, drainage 
is rendered almost impossible, and every facility 
is given for the gravitation of the effusion of 
the wound into the depths of the foot. If the 
flaps have been carelessly cut, if the tendon- 
sheaths have been left open, if the wound is 
not perfectly aseptic and if the foot is so 
placed that proper drainage is impossible, it 
is no matter for wonder that the stump does 
not do well, and that deep-seated suppuration 
is detected in the foot. 

After Lisfranc's and Hey's amputations the 
limbs may be allowed to lie upon one or the other side with the knee 
flexed. The pillow supporting the foot should be firm; the stump may 
project a little beyond the end of the pillow, and to this support the leg 
may be lightly secured. 

After Chopart's operation and after the subastragaloid amputations 
the stump should be supported upon a back-splint, which is kept a 
little raised by a firm pillow or cushion. By this means the heel-flap is 
supported, and the os calcis in the Chopart operation is to a great extent 




Fig. 134. — Lines of Incis- 
ion for Amputation 
of Toes and Meta- 
tarsal Bones. — (Stim- 
son.) 



41 POSTOPERATIVE TREATMENT. 

kept from altering its position. The knee should be a little flexed, and 
the stump may be inclined laterally, so as to favor drainage. The splint 
employed is an ordinary straight back-splint, suitably padded. A pad 
is introduced beneath the tendo-Achillis. The skin is protected by a 
piece of guttapercha molded to the limb and lined with lint. The splint 
is secured by straps and buckles. 

Drainage-tubes should not be employed unless actually necessary, 
and should never be passed right across the angle of the wound, from 
one extremity of the incision to the other. A small piece of tubing may 
be introduced at each of the two corners of the wound — as in Hey's, 
Lisfranc's, and Chopart's amputations— and sutures at these points 
may be omitted. In any case the tubes should, under ordinary circum- 
stances, be removed in twenty-four hours. 

In the subastragaloid operations, when a heel-flap exists — with a 
pouch left by the removal of the os calcis — a hole may be made through 
the center of that flap into the pouch, and a short tube introduced. 
This need not be retained more than one day. When the major flap is 
formed from the heel or sole, it should be remembered that the tissues 
of those parts are usually tough and unyielding, and that consequently 
an undue strain comes upon the sutures. These should be deeply 
inserted, and should not be removed too soon. In a "Syme" they may 
often be retained for ten days. After their removal it may be necessary 
to support the flap with strips of adhesive plaster. 

Care must be taken that the pad of the splint does not press unduly 
upon the extremity of the stump. This splint serves to support the heel- 
flap, and, in the case of the intracalcaneal amputations, it helps also 
to keep the osseous surfaces in contact and to restrain the action of the 
muscles of the calf. 

The knee should in all instances be a little flexed, and the stump 
may, when required, be inclined a little laterally, to favor drainage. 



CHAPTER XVII. 
EXCISIONS OR RESECTIONS OF JOINTS. 



CHAPTER XVII. 
EXCISIONS OR RESECTIONS OF JOINTS. 

EXCISIONS OF JOINTS. 

The Kocher Method. — The modern method of typical excisions 
which is most worthy of recommendation seems to us to be the following : 

i. To employ as simple an incision as possible (Langenbeck), special 
care being taken not merely to place it in the intervals between the mus- 
cles, ligaments, and tendons, but to carry it down to the bone in such a 
way that the smallest vessels and nerves can be avoided, and also to 
place it in the frontier line between the muscles supplied by different 
nerves. 

2. To detach subcortically the capsule, the periosteum, and the 
ligamentous and tendinous attachments, and to remove all the diseased 
bone with the articular extremities, should this be deemed necessary in 
order to obtain a better functional result. If attention be paid to these 
points with strict aseptic precautions, arthrotomy can be undertaken 
with benefit in the early and mild stages of joint disease. (Kocher.) 

Essentials of After-treatment. — It is obvious that in excisions the 
limb should be immobilized in a plaster bandage, so that the new articular 
ends may be kept firmly in contact in good position. Where there is 
any difficulty in maintaining them in position, it may be necessary to 
wire the ends together in such a way as to retain them in the desired 
position without ultimately preventing the proper movement. Lane 
has made use of this plan with very good result in old-standing affections 
of the hip-joint. Healing usually occurs rapidly, and if the w r ound 
remains aseptic, the patient may begin passive movements in fourteen 
days in the case of the upper extremity, while in the case of the lower 
extremity he may be allowed to go about with the limb in plaster. The 
sooner movement is begun, the better will be the result, even if it is only 
very slight movement inside a well-padded plaster case. To obtain 
early restoration of function it is essential to get rid of the sensitiveness 
of the sawed ends of the bone as soon as possible. Where ankylosis 
is desired, as in excision of the knee-joint, firm fixation is the best means 

4i3 



414 



POSTOPERATIVE TREATMENT. 



of obtaining this object, the limb being placed at once in a plaster cast. 
To obtain firm union, the bones must fit accurately together, or they 
may be wired or nailed together. To obtain, rapidly, comparative insen- 
sitiveness in the ends of the bone in case a movable joint is aimed at, 
Kocher adopts the following procedure, which he terms "the dislocation 
or secondary reposition method" : "In the elbow and hip, for example, 
after resecting the ends of the bones we bring them into a dislocated 
position, so that the sensitive sawed ends of the bones are merely in 
contact with the soft parts; after ten to fourteen days, when the skin 
incision is quite healed, they can be easily placed in proper position. 

3 , 




. Fig. 135. — Hoppe's Universal Adjustable Splint. 
a, b, c, Steel or aluminum connecting rod; movable joint at b; d, forearm splint; e, arm 
splint; /, thumb-set caps or screws. 

The patient then begins at once to move the limb, which by the usual 
method he is quite unable to do, however much he may desire to. It 
is essential, too, that the movements of the muscles should be begun 
early, if the function of the joint is to be restored quickly. By means 
of an apparatus provided with the means of elastic flexion and extension, 
while the axis of movement is maintained, the treatment is greatly as- 
sisted." 

Excision of the Shoulder- joint. — In excising the shoulder- joint 
it is very important to remove as little of the bone as possible, for the 
reason that it is necessary to leave the attachment of the rotator muscles 
intact if this can be safely done; this permits rotation of the arm, whereas 
after the old operation, in which the rotators were completely cut across 



EXCISIONS OR RESECTIONS OF JOINTS. 415 

and the bone was sawed on a Level with the surgical neck, the resulting 
limb was very useless. Before the wound is closed with stitches it is 
advisable to insert a drainage-tube at the lower angle of the wound for 
a few days, as a considerable cavity is left which may become distended 
with blood and serum. The tube is usually removed about the third 
day. After the usual gauze dressings have been applied, a large w T edge- 
shaped pad is placed in the axilla to prevent displacement inward of 
the upper end of the humerus. It is well also to place a firm pad over 
the front of the joint, because the upper end of the bone is apt also to 
be drawn forward. The wedge-shaped pad should extend as far down 
as the elbow, and the forearm should be flexed and supported by a 
splint. The hand should not be bound to the side. 

After-treatment (Cheyne-Burchard, " Manual of Surgical Treat- 
ment"). — So soon as the wound is healed the arm may be fixed 
in proper position by a starch or plaster bandage, and after two weeks, 
passive movements should be begun; the period at winch the passive 
movement should be employed depends largely upon the healing of the 
incision and the amount of bone removed. If the whole of the upper 
end of the humerus has been removed and the rotators divided, the 
elbow should be supported and the arm fixed for four or five weeks, as 
otherwise a very lax joint is likely to result. If, on the other hand, the 
operation we have described is sufficient, passive movement should be 
begun after the fourteenth day. Special attention must be paid to 
preserving rotation, which is the movement most likely to be lost; abduc- 
tion should also be carefully attended to. The axillary pad and the 
wrist-sling should be continued for six or eight weeks. 

Sir Frederick Treves suggests the following: The upper end of 
the humerus is to be brought into contact with the glenoid fossa. The 
arm is secured to the side, the hand rests in a sling. A large pad of 
cotton- wool is introduced into the axilla. This pad is intended to support 
the bone, to assist in fixing the parts, and to counteract the tendency 
which will be exhibited for the upper end of the humerus to be drawn 
inward under the coracoid process. This displacement is especially 
apt to occur when the external rotator muscles have been divided, and 
there is little to withstand the action of the pectoralis major and latissi- 
mus dorsi. The size of the pad must be regulated according to the needs 
of the case. It should be of triangular outline, with the base upper- 
most. The pad is likely to fail, if it fail at all, from being too small 
rather than too large. Xo splint is required. 



41 6 POSTOPERATIVE TREATMENT. 

Passive movements of the fingers, wrist, and elbow may be commenced 

within a day or two after the operation. Yen- gentle passive movements 
of the shoulder may be first attempted at the end of some fourteen days. 
These movements should consist of flexion and extension, of slight 
rotation, and of still slighter abduction. The latter position tends to 
throw the end of the bone inward — or, rather, to assist the disposition 
to that deviation. Massage, electricity, and active movements will 
follow in due course. The arm may be allowed to hang, with no other 
support than a sling, at the end of four or five weeks. 

Results. — The results of this operation are very satisfactory. The 
mortality of the operation is slight. More than two-thirds of the sub- 
jects of the operation recover, with quite useful limbs. In many in- 
stances the restoration of fimction has been remarkable. As a rule r 
flexion and extension are freely performed, and the patient can lift con- 
siderable weight. Adduction also is well accomplished. On the other 
hand, rotation movements and abduction are feebly performed. The 
arm cannot be lifted beyond a right angle with the trunk. It is after 
the subperiosteal operations that the best results have been obtained. 
There is a tendency, as already stated, for the upper end of the bone 
to assume the position occupied by the head in subcoracoid dislocation. 
Ankylosis appears to result more frequently than a flail-like joint. 

Excision of Elbow. — After-treatment. — Treves states that after 
the operation the limb must be placed upon a suitable splint and the 
bones so adjusted that the greater diameters of the bony surfaces cor- 
respond and do not cross. The hand should be in the mid-position 
between pronation and supination, and the elbcw be very slightly bent 
— so slightly that the forearm will be nearer to the extended posture 
than to the position it occupies when at right angles to the arm. The 
precise angle recommended by most surgeons is an angle of 135 degrees. 

Very many forms of splint have been devised. The main require- 
ments of such appliances are that they may be light, strong, rigid, easily 
kept clean, and do not interfere with the drainage and dressing of the 
wound. In many cases a splint may be dispensed with, the support of 
the dressings and a pillow being sufficient. 

Hausmann's combined splint for excision of the wrist or elbow answers 
its purpose well, and also permits the joint to be exercised without the 
splint being removed. The fingers should be free. The splint and 
limb may be at first suspended from a cradle, or supported upon a pillow 
with sand-bags. 



EXCISIONS OR RESECTIONS OF JOINTS. 



417 



It must be borne in mind that there is some disposition for the bones 
oi the forearm to be displaced backward, that too wide a distance be- 
tween the bones may lead to a flail-like joint, and that if, on the other 
hand, the sawed surfaces be kept in close contact, in young subjects 
bony ankylosis may ensue. The relative position of the bones can 
always be estimated by a skiagram. 

In general terms, it may be said that to insure a false joint the bones 
should be separated for the distance of half an inch. After a successful 
excision by the subperiosteal method in healthy subjects the disposition 
to ankylosis is considerable. As ankylosis is especially to be feared 
in children, the limb may be put up from the first on a right-angle splint, 
such as that recommended for the purpose by Jacobson, with a movable 
or adjustable joint at the elbow. When also a considerable quantity 
of bone has been removed, the 
use from the commencement 
of a rectangular splint is ad- 
vised by many. 

Passive movements of the 
fingers and shoulder, and 
flexion and extension of the 
wrist, should be commenced 
as soon as possible after the 
operation — possibly by the 
third day — and should be 
continued daily. Passive 
movements of the elbow may commence about the tenth day, provided 
that the healing process has proceeded favorably and the measure can 
be borne by the patient without undue pain. In children such move- 
ments may at first be required to be carried out under an anesthetic. 
When four or five weeks have elapsed, the forearm may be gradually 
brought up until it forms a right angle to the arm. At the end of six 
or eight weeks the splint may be dispensed with, and the movements 
of the elbow should be free. Active movements, aided by massage and 
galvanism, should now be advised; and within four months from the 
time of the operation the new joint should have acquired solidity and 
be capable of exhibiting a free and extensive range of movements. 
. Excision of the elbow has led, on the whole, to very satisfactory results, 
and in a large proportion of the more favorable cases the results have 
been most admirable. Even if ankylosis occurs at a right angle, the 
27 




Fig. 136. — Elbow Splint. — (Strohmeyer.) 



4i8 



POSTOPERATIVE TREATMENT. 



limb is in a better condition than it was while diseased. In the more 
unfortunate instances repair is imperfect for various reasons, and a 
very loose false joint, resulting in a flail-like limb, is the final production. 
Even in such a case a good deal may be done by means of a suitable 
splint; the apparatus shown in Fig. 136 has proved most efficient. It 
consists of two pieces, one of which grasps the upper arm and the other 
the forearm, the two being connected by a metal band over each side of 
the elbow, jointed to permit of flexion and extension. This apparatus 
prevents lateral mobility, and, if worn for some months, it is quite pos- 
sible that a joint which was at first very lax may finally be quite satis- 
factory. 

RESECTION OF JOINTS. 

Resection of the Wrist-joint. — After resection of the wrist- joint the 
wrist should be dressed as nearly straight as possible, Esmarch's interrup- 




Fig. 137. 

ted splint (Fig. 137) being applied. The results of this operation vary 
very 'much, and on the whole are not satisfactory. The splint must 




Fig. 138. — Proper Method or Applying Bandage After Operations on Fore- 
arm, Wrist, or Hand. 



be worn for a very considerable time — three to six months — and there 
is a tendency for the hand to fall into position of adduction. 



I XTISIONS OR RESECTIONS OF JOINTS. 



419 



Passive movement of the lingers is begun on the second day, whether 
the inflammation has subsided or not, and continued daily. Each joint 
should be flexed and extended to the fullest extent possible in health, 
the metacarpal bone being held quite steady to avoid disturbing the 
wrist. By this means the suppleness gained by breaking down the 
adhesions under chloroform is maintained. 

Pronation and supination, flexion and extension, abduction and adduc- 
tion, must be gradually encouraged as the new wrist acquires firmness. 





Fig. 139. — Thomas's Hip Splint. 



Fig. 



140. 



-Schaffer's Hip Splint. 



When the hand has acquired sufficient strength, freer play for the fingers 
should be allowed by cutting off all the splint beyond the knuckles. 
Even after the hand is healed, a leather support should be worn for 
some time, accurately molded to the front of the limb, reaching from 
the middle of the forearm to the knuckles, and sufficiently turned up 
at the ulnar side. This is retained in situ by lacing over the back of the 
forearm. 



420 POSTOPERATIVE TREATMENT. 

Resection of Hip. — General Considerations. — After the excision 
and arthrectomy have been completed, the hemorrhage carefully arrested, 
and the acetabulum thoroughly cleaned with a sharp spoon, the tro- 
chanter is replaced and fixed in position with an aseptic bone or ivory 
nail, aided by sutures of catgut embracing the periosteum and the dense 
fascia. In a number of cases Senn has relied on suturing with catgut 
exclusively in immobilizing the trochanter, and had the satisfaction of 
observing that the trochanter w T as perfectly held in place until bony 
union was sufficiently firm to dispense with direct means of fixation. 
The acetabulum is drained with a tubular drain and iodoform gauze, 
which are brought out through a separate opening behind the resection 
wound. The dressing must be large, embracing the upper half of the 
thigh and the same side of the pelvis as far as the crest of the ilium. As 
a primary immobilization dressing a long external splint with foot- 
board and extension by weight or straps will be most comfortable and 
efficient (Fig. 139 and Fig. 140). So soon as the patient is able to leave 
his bed, a plaster-of-Paris dressing is relied upon in securing fixation 
and in guarding against undue shortening. 

Hueter's anterior incision for resection is now rarely employed except 
for exposing the acetabulum in congenital dislocation of the hip or in 
operations upon children. The posterior incision gives much more 
room and admits of better drainage, and is now universally adopted as 
giving better results. 

After-treatment. — When the patient is placed in bed, extension 
should be employed, a weight of three or four pounds being used for a 
child, the limb being in the abducted position, all motion and rotation 
being prevented by a properly adjusted splint (see Fig. in). A Liston's 
long splint is very frequently used, and applied to the sound side from 
the axilla to beyond the toes, so as to prevent any flexion of the hip- 
joint. The patient should be laid upon a mattress divided in three parts 
in order that the central portion may be removed for nursing purposes 
without necessitating any disturbance. 

The extension and fixation of the limb should be kept up for about 
six weeks; at the end of that time a Thomas's hip splint (seepage 419) 
may be employed. This should be bent well outward opposite the joint 
so as to keep the limb in the abducted position; the splint should be 
provided with a pelvic band. In quite young children, who are very 
difficult to keep quiet, either a double Thomas's splint well padded or 
a simple Phelps's box splint will be better than the single splint. Con- 



EXCISIONS OR RESKCTIONS OF JOINTS. 



421 



trary to the common recommendation, we very strongly advise that 
the patient should not be allowed to walk or to bear any weight on the 
limb for several months — at least six or eight after the operation, when 
the patient may be placed in an ambulatory splint. If this be done, 




Fig. 141. — Ambulatory Splint. 



the consolidation of the structures in the neighborhood of the joint will 
give a much firmer joint than is otherwise obtainable. It is very seldom 
that anything like bony ankylosis occurs, but if a movable joint be 
desired, this may be assured by performing passive movement of the hip 



422 



POSTOPERATIVE TREATMENT. 



through a limited range twice a week after the wound has healed. The 
patient need not be kept in bed longer than the third or fourth week. 
He may be allowed to get about on crutches with an ambulatory splint, 
or a high boot on the sound foot so as to avoid any risk of the affected 
foot being put on the ground. 

When excision is employed in the later stage of the disease, where the 
disease has been cured and the operation is only done for the deformity, 
mere removal of the head of the bone is all that is necessary; the removal 
of the capsule is not called for, as the disease has disappeared. 'The 
object of the operation in these cases is simply to get rid of the head ; of 
the bone so as to obtain a movable joint. 




Fig. 142. — Anterior [Leg [Splint, for Resection of the Knee-joint, Fitting 

Either Side. 




Fig. 



143. — Posterior Leg and Thigh Splint, for Resection of the Knee-joint, 
Fitting Either Side. 



If sepsis occurs, the after-treatment is tedious and uncertain, and 
frequently demands considerable mechanical skill in the application of 
splints, and at the same time permits surgical dressing to be applied 
when the wound is suppurating. The open-wound method of treat- 
ment is always preferable, and the after-treatment does not vary from 
methods already described under the head of "Treatment of Septic 
Wounds." In these prolonged cases the ambulatory splint (Fig. 141) 
not only assists in the radical cure, but renders the patient more com- 
fortable and permits him to be up and around. 



EXCISIONS OK RESECTIONS 01 JOINTS. 423 

Excision or Resection of the Knee-joint. — The after-treatment 

is of the utmost importance, is tedious, and often surrounded with 
difficulties. There is a tendency to displacement, and notably to a 
displacement of the tibia backward. If sound healing does not take 
place, the limb is worse than useless, and the flail-like limb that 
may result is of less service to the patient than a good artificial leg. 

The limb must be put up perfectly straight — i.e., in the position of 
complete extension — and for the purpose of fixing it many surgeons 
employ plaster-of-Paris. The rigid dressing formed of this material 
is not entirely satisfactory. It may exercise an unequal pressure upon 
the parts, and may lead to edema, etc. Discharge may rind its way 
between the splint and the limb, the dressing is difficult to remove, and 
even when large "windows" are provided the inspection of the part 
can never be so complete as it should be (Fig. 112). 

A splint should be provided which will allow the bones to be kept 
in good position, will permit free inspection and examination of the 
wound, and will not interfere with dressing and drainage should drainage 
be necessary. 

The ordinary posterior leg-and-thigh wire splint (Figs. 142, 143) 
for resection of the knee-joint is quite popular with some surgeons, 
but the wire, when the heel touches, should be removed, cut or bent out 
to avoid pressure. It is retained and held in place by gypsum bandages 
to immobilize the part above and below the knee. The knee itself is 
dressed and so protected that it can be examined without disturbing the 
other dressings. It is well that the splint should be suspended. Marsh 
points out that "the plan of firmly bandaging the lower end of the femur 
to the back-splint leads to great swelling about the wound, and materi- 
ally retards repair. It is apt also to induce persistent venous oozing 
after the operation." To avoid these drawbacks, he employs Gant's 
splint. This simple splint, instead of binding the femur down to the 
level of the tibia, brings the tibia up to the level of the femur, and no 
tight bandaging is called for. 

A splint which answers admirably in the after-treatment of excision 
of the knee is Hodgen's suspension splint (Fig. 144). 

Quite a number of the splints employed have the disadvantage of 
being complex and difficult to adjust. Dry dressings should be applied 
to the wound and should not be changed oftener than is absolutely neces- 
sary. If silver wires are used to maintain the bones in apposition, they 
are allowed to remain, but if nails have been used, thev should be re- 



4 2 4 POSTOPERATIVE TREATMENT. 

moved at the end of the third week. The dressings should not be changed 
as a rule, except to remove the drainage-tube. The limb must be kept 
upon the splint until it is sound. This period will vary from six weeks 
to three months. Complete recover}' can usually not be expected until 
six months have elapsed. 

After the splint has been removed, a light leather support, strength- 
ened with a strip of steel at the back, should be applied; and in the case 
of children the support must be worn for two or three years. A thick- 
soled boot will be required to -meet the inevitable shortening, which, 




Fig. i44- 

however, in the most favorable cases, does not amount to more than 
about an inch. 

Excision of Knee- joint (Chevxe's Method). — The bleeding is 
arrested and the wound stitched up, but before doing so it is well to 
wire the femur to the tibia; this is not absolutely essential, but it keeps 
the limb in position while the dressings are being applied, and it serves 
to prevent any antero-posterior dislocation of the bone surfaces. It 
must be remembered that the divided surface of the tibia is much broader 
than that of the femur, and if, therefore, the anterior margins of the 
two bones be brought into apposition, the posterior surface of the tibia 



EXCISIONS OR RESECTIONS OF JOINTS. 



425 



will project markedly into the popliteal space, and when the limb is 
placed upon the splint, pressure may be exerted upon the popliteal 
artery, and gangrene of the limb may result. The posterior margins 
of the bones should therefore be accurately adjusted, and it is with the 
view of securing this that fixation of the bones is advisable. Some 
trouble may, however, be caused from the extreme softness of the bone, 
winch allows the wires or pegs to cut through considerably, and, there- 
fore, great care must be taken to keep the limb in proper position after 
the wire has been introduced. 

As a rule, it is well to introduce a drainage-tube at the outer edge 
of the incision, the rest of which is sewed up by 
a continuous suture; the limb is placed upon a 
Thomas knee splint (Fig. 143). 

Ajter-treatment. — When a drainage-tube has 
been used, the dressing must be changed in three 
days, at which time the tube may be removed. 
When changing the dressing it is well to have a 
fresh splint prepared in a manner similar to the 
original. The splint is then opened and the front 
of the knee dressed; while this is being done 5 an 
assistant must fix the thigh to prevent starting of 
the limb, while another similarly fixes the leg. 
It is well, in fact, at the first dressing to keep 
the limb in firm contact with the splint by open- 
ing one side at a time while the limb is pressed 
against the other, and one side is washed and 
dressed at a time. The splint is elevated, the 
inclined plane or pillow upon which it is resting 
is removed, and then the splint is opened. One 
assistant grasps the thigh and another the leg, 

while the surgeon grasps the limb on either side of the knee; the splint 
is then allowed to drop away from the limb, the posterior part of which 
is thoroughly washed with a 5 percent carbolic acid solution and after- 
ward with a 1 : 1000 mercuric chlorid solution. The fresh splint, 
with dressing already arranged, is put in place beneath the limb and 
gradually raised until the surgeon and the assistants can remove their 
hands and leave the limb lying upon the fresh splint. The strips of 
gauze are then wrapped around the knee and the dressing, and the 
splint is bandaged on. 




Fig. 145. 



426 POSTOPERATIVE TREATMENT. 

It is well at this dressing to impregnate the outside bandage with a 
starch solution, so as to prevent it stretching and to insure that the 
apparatus will keep firm for six weeks or so, at the end of which time 
it may be taken off, the stitches removed, and the limb put up in plaster- 
of -Paris or some similar immovable apparatus. 

In three months after the operation union is usually firm enough for 
the patient to get about without any apparatus. Massage may be re- 
quired for two or three weeks afterward to restore the circulation and 
improve the nutrition of the muscles. 

Excision of Ankle-joint. — Excision of the ankle is now seldom 
performed, as it nearly always results in bony ankylosis. Arthrectomy 
of the joint with removal of the astragalus is far more satisfactory and 
leaves the patient with a more useful limb. 




Fig. 146. — YoLKiiAXx's Dorsal Splixt for Excision of the Ankle. — (DaCosta.) 

Aeter-treatmext for the operation is as follows: The dressings 
should be changed in a fortnight, when the wound should be healed, and 
the stitches may be removed. The limb may now be put up in plaster- 
of-Paris, taking care to keep the foot strictly in its normal position. The 
plaster casing should be maintained for about six weeks, when it should 
be removed. The patient should not be allowed to walk until six or 
eight months have elapsed from the time of the operation. 

The chief trouble after arthrectomy of the ankle is the tendency to 
lateral deviation of the foot — more particularly inversion — and this 
must be carefully guarded against by the use of apparatus until the parts 
have become quite firm. Afterward the patient must wear a suitable 
boot designed to prevent lateral displacement. There is no fear of the 
mobility of the limb becoming impaired, even though the joint be kept 
in plaster for six months, because the os calcis does not unite firmly to 
the tibia and a very excellent movable joint results. 



EXCISIONS OR RESECTIONS OF JOINTS. 427 

RESULTS OF EXCISION OPERATIONS. 

The advantages claimed for the subperiosteal method are the 

following : 

(a) The periosteum being preserved, new bone is formed to replace 
that which has been removed. 

(b) The capsule of the joint is preserved, and the connections of the 
ligaments are not severed; the new articulation is therefore likely to be 
all the stronger. 

(c) The connections of the tendons with the periosteum are not dis- 
turbed, and greater muscular strength is consequently given to the new 
joint. 

(d) There is much less hemorrhage, the chief area of the operation 
being subperiosteal. 

(e) Planes of connective tissue are not opened up, and the cavity 
left after the removal of the bones is limited and circumscribed by the 
capsuloperiosteal sheath. 

With regard to these claims, there is no doubt that, in favorable cir- 
cumstances, a large quantity of new bone is produced to make good 
that lost by the operation. The importance of the periosteum in this 
connection would appear to be paramount, although some recent writers 
have adduced evidence in support of the view that the bone-forming 
functions of the periosteum have been overestimated. 

In the most successful cases it cannot be said that the articular ends 
of the bone are reproduced, and that the new joint is a reproduction of 
the old. New bone is formed, and fills, in part, the periosteal cavity 
and by the periosteum it is limited and molded. The new bone is, as it 
were, poured into a mold. The amount produced varies. In some 
instances no new bone is produced, even when a considerable portion 
of the periosteum is saved; in other cases an excessive amount is 
found to have been formed; in a few examples the reproduction of 
the details of the lost bones has been precise and remarkable. In 
all circumstances it would appear that the new bone is a little unstable, 
and that it is liable to undergo a certain but varying amount of resorp- 
tion. 

The value of the new bone so produced cannot be overestimated 
when the results of operations come to be compared, and the main 
advantage of the subperiosteal method may be considered to be based 
upon this feature. The preservation of ligaments and tendinous con- 



428 



POSTOPERATIVE TREATMENT. 



nections is another advantage of this method — an advantage that is 
substantial and definite. 

The disadvantages of the subperiosteal operation cannot, on the 
other hand, be overlooked. The measure is admirable in theory, but it 
does not always assume so immaculate a position in practice. In the 
first place, the operation is often impossible. The detachment of the 
periosteum is difficult and tedious. In traumatic cases, in adults, the 
surgeon will find in practice that the strict carrying out of the method 
of Oilier is barely possible. 

The operator who blindly persists in following this method will often 

find, that, after much valuable time has been 
exhausted, he has bared the bone of perios- 
teum, but has left that membrane in shreds 
and holes. In young subjects the periosteum 
is thicker, more active, more substantial, and 
more easily stripped off. It may also be said 
that it is more precious, and is in more need 
of being preserved. 

In cases attended by chronic inflammation 
the periosteum is generally very easily de- 
tached, but in such a condition it is often 
of doubtful value. It may be infiltrated 
with inflammatory or tuberculous material, 
may hinder the healing of the wound, and 
may even maintain suppuration. But if it 
lack these potentialities for evil, it may pos- 
sess no bone-producing property. 

In the next place, the subperiosteal oper- 
ation involves a considerable period of time 
in the performance, and the shock following 
the- procedure may be considerable. In this respect it compares un- 
favorably with an excision by the open method, where the actual steps 
of the operation are simple and the process quick. 

The open method, practised as it was in the earlier days of surgery, 
when ligaments and tendons were divided without scruple, may be 
safely regarded as a matter of the past; but such a modification of this 
method as the subperiosteal procedure suggests is of great value. 

Summary. — So far as excision of joints are concerned, the conditions 
that may be considered under this heading are very numerous and can 




Fig. T47 — Bone Denuded of 
Periosteum, Result of 
Chronic Inflammation. 



EXCISIONS OR RESECTIONS OF JOINTS. 429 

only be dealt with in outline. They concern not only those general 
circumstances that influence the healing of wound and the recovery 
of patients after operation, but embrace certain local features that are 
more or less obvious. 

The success of the operation will depend upon the age of the patient, 
upon his condition, upon his powers of exhibiting repair from exten- 
sive wounds, and upon the general circumstances that affect primary 
healing. His nervous condition is a matter of importance, as is also 
his capacity for submitting to tedious and often painful after-treatment. 
The question of perfect asepsis needs but to be mentioned. So far as 
the operation is concerned, much will depend upon the state of the tis- 
sues, upon the nature of the disease, upon the amount of bone removed, 
upon the complete elimination of the morbid structures, and upon the 
safety of important tissues in the vicinity of the operation. 

Few operations can be cited in which the after-treatment is more 
important, and in which is has a greater influence upon the success of 
the case. However well the excision may have been carried out, and 
however favorable the case may be, the whole complexion may be altered 
and transformed by neglect in the after-treatment. 

The wound must be kept aseptic, and in general terms it may be 
said that dry and infrequent dressings should be mainly relied upon. 
The splint must be selected with care, and must be applied with pre- 
cision. The principal features in the after-treatment are identical with 
those attending the care of compound fractures. 

The position of the limb must be accurately prescribed. If anky- 
losis is wished for, the bones must be brought into close contact, and 
must be kept in very rigid relation to one another. If it be intended 
that a movable articulation shall result, then the approximation of the 
bones should be less close. No rule can be given that will render defi- 
nite the precise degree of separation of parts that is desirable after the 
operation. The approximation will be less close in adults than in young 
subjects, and in cases in which much periosteum has been preserved 
than in those where much has been lost. It may be that a week or so 
will have to elapse before the surgeon can satisfy himself that the adjust- 
ment of the sawed ends of the bones is the best that can be attained. 

Skiagraphy is very useful in determining the treatment of excision. 
In some instances, notably those associated with existing deformity 
of the joint, it may not be wise to enforce the ideal position at once, but 
the limb will have to be brought gradually into the desired attitude. 



43 O POSTOPERATIVE TREATMENT. 

When mobility is desired, passive motion will have to be undertaken. 
This may be commenced so soon as the inflammatory symptoms have 
subsided, and so soon as the sensitiveness of the part has become less 
acute. In most cases this will be represented by a period varying from 
one to three weeks. Passive motion should not be begun until the opera- 
tion wound has soundly healed. The treatment of the general health, 
the duration of the treatment by apparatus, and the employment of mas- 
sage and electricity will depend upon general principles. 



CHAPTER XVIII. 

OSTEOMYELITIS, OPERATIONS FOR CLUB- 
FOOT, OSTEOTOMY FOR GENU 
VALGUM, ETC. 



CHAPTER XVIII. 

OSTEOMYELITIS, OPERATIONS FOR CLUB-FOOT, OSTEOT- 
OMY FOR GENU VALGUM, ETC. 

OSTEOMYELITIS. 
CHRONIC OSTEOMYELITIS. 

The postoperative treatment of chronic osteomyelitis depends 
entirely upon the operative technic. Neuber's implantation of skin- 
flaps, by bringing the cutaneous edges together into the defect and trans- 
fixing with nails or fastening by catgut sutures, was the first step in the 
direction of accelerating the cure of necrotomy wounds. Schede's 
plan has the great advantage over Neuber's method, that it can be 
employed successfully under the most varied conditions. It is independ- 
ent of presence or absence of sufficient covering by skin, which commends 
it to the attention of the surgeon. (Gerster.) 

The indispensable conditions for a successful employment of Schede's 
method are laid down in the following propositions. (Gerster's " Sur- 
gery.") 

First. Thorough exposure of the seat of the disease by incision and 
by the use of mallet and chisel. 

Secondly. Complete removal of the whole sequestrum, or all the 
sequestra, and of the entire pyogenic membrane fining the cavities and 
sinuses, by scooping and scraping with the sharp spoon. 

Thirdly. Thorough disinfection of all the nooks and crevices of the 
wound by a vigorous use of the irrigator and corrosive-sublimate lotion, 
and by wiping it out with a clean sponge. The final flushing and mop- 
ping out should always be done with the strongest solution of corrosive 
sublimate used by surgeons (1:500). Residua of this strong lotion are 
then washed away by a mild solution to prevent mercurial poisoning. 

Fourthly. The formation of a blood-clot which should fill up the 
wound to the level of the skin, and its preservation from putrefaction 
and exsiccation by a suitable antiseptic dressing. Leaving behind the 
smallest spicula of undetected dead bone, or a shred of the pyogenic 
membrane, will partially or totally compromise the success of this pro- 
28 433 



434 POSTOPERATIVE TREATMENT. 

cedure, and no amount of irrigation will avert suppuration. Fulfill- 
ment of the second proposition is not difficult except in the disseminated 
form of necrosis, where a number of small foci, each containing its 
sequestrum, and all connected by more or less narrow and tortuous chan- 
nels, are scattered within a wide area of the affected bone. But even 
these difficulties can be overcome by the exercise of circumspection and 
painstaking, favored by artificial anemia, which renders detection of 
discolored bone and the entrance to bone sinuses comparatively easy. 

Nichol's Method of Operation and Postoperative Treatment of 
Chronic Osteomyelitis. — (Abstract from article by Dr. E. H. Nichols, 
Boston, Mass., "Am. Med. Jour.") 

The operation consists of an incision through skin and ossified peri- 
osteum down to necrotic shaft, reflection of the periosteum, removal 
of the shaft, either entire or partial, folding of the plastic periosteum 
in such a way as to approximate the internal layers, suture of the edges 
by absorbable sutures, suture of the soft tissues, with, in both cases, 
provision for moderate drainage and complete immobilization. After 
removal of the necrotic shaft well-marked ossification of the new peri- 
osteal shaft appears between the twentieth and fortieth days, and the 
shaft is solid enough for use in locomotion in from four to eight months. 
If the epiphyseal fine is extensively destroyed, considerable shortening 
of the limb may result. 

This is the operation of preference, and is especially applicable when 
an accessory bone which can act as a splint is present. The best time 
for the operation ordinarily is about two months after complete drainage 
of the acute infection. 

The anatomic, functional, and cosmetic results obtained by this 
operation are much superior to those obtained in any other way in cases 
of large bony defects due to acute infection of bone. 

The chief difficulty in completing the restoration of the shaft is to 
obtain complete union of the regenerated shaft to the epiphyseal fine 
or to the portion of the normal shaft that remains. Slight necrosis 
and suppuration may persist at this point after the repair otherwise is 
complete, and may demand minor operations to remove small frag- 
ments of necrotic bone. Union at these points may be delayed, but 
ultimately always has taken place. When no accessory splint is present, 
it may be impossible, in special cases, to maintain the contour of the 
affected bone by the above-mentioned method. In such cases advan- 
tage can be taken of the power of central growth possessed by the shell 



OSTEOMVK LITIS. 



435 



of 'periosteal bone in its early stages. This means that the necrotic 
bone must be removed just as soon as the periosteal shell is sufficiently 
advanced and solid to maintain contour and bear the weight of the limb. 
Roughly, this stage is reached when the thickness of the periosteal shell 
is equal to one-fourth of the diameter of the original shaft. The time 






] 


& m 




— — 








, ■ 


II 



Fig. 148. — Recovery after Partial Re- 
sect iox of Humerus. — (Nichols.) 



Fig. 149. — Recovery from Chronic 
Osteomyelitis. — (Nichols.) $ 



when this condition exists can be determined by Rontgen-ray examina- 
tion and by palpation. 

If the necrotic shaft is removed at this time, it leaves a solid cylinder 
of periosteal bone, very vascular, but partly calcified, analogous to the 
bone seen in an early external callus, and this shell has sufficient power 
of central growth to fill up large cavities. The rate of central growth 
seems to be markedly slower than that of peripheral growth. Persist- 
ence of sinuses is longer than in the preceding method, partly from a 
failure to remove small fragments of necrotic bone at the time of opera- 
tion. 



436 POSTOPERATIVE TREATMENT. 

Finally, the most satisfactory results in treatment of acute osteo- 
myelitis can be obtained by complete drainage of soft tissues and marrow 
in the acute stage, with the removal of extensive necroses, if they occur, 
at a secondary operation undertaken about two months later, and by 
adaptation of the regenerative power of the periosteum for the forma- 
tion of a new shaft. 

After-treatment. — Certain precautions and difficulties in the opera- 
tion and after-treatment should be considered. Of course, some 
infection and suppuration will be present when the operation is done, 
but they should be minimized as far as possible, For this purpose 
free incisions, followed by careful daily dressing and irrigation, should 
be provided for some time before removal of the shaft when necessary. 
Often the reaction to the inflammatory process in the soft tissues and 
periosteum leads to the formation of an enormous amount of vascular 
granulation tissue in the soft parts about the bone. Incision of such 
parts may lead to great oozing hemorrhage during the operation, suffi- 
cient at times to make the operation dangerous from loss of blood. 
This may be avoided by the application of an Esmarch bandage before 
the operation and removal after the dressing. I have known of two 
cases where the hemorrhage was so severe as to require that the opera- 
tion be done in two steps; at the first step periosteum was partly 
peeled back from the bone and the operation completed some days later 
after hemorrhage had ceased. 

In regard to closing the wound, it is to be remembered that the opera- 
tion practically never is done on perfectly aseptic tissues. Some sup- 
puration may take place between the approximated surfaces of perios- 
teum, and some is sure to take place between the soft tissue edges. 
Consequently it is advisable to leave the stitches in the periosteum as far 
apart as is possible with accurate approximation of the edges. The 
edges of the soft tissue may be closely approximated, but provision for 
drainage should be made by very small gauze wicks or catgut drains. 

The operation produces moderate depression, not so severe as an 
amputation. In spite of all precautions there is likely to be some 
evidence of septic absorption, which makes its appearance on the second 
or third day, but usually disappearing within a week. In two cases 
the postoperative infection was sufficient to cause mild delirium for 
several days. 

The wound may heal by first intention over the greater portion, but 
some redness and slight sloughing of the edges may appear. In one 



OSTEOMYELITIS. 437 

case this sloughing was sufficient to cause considerable gaping both of 




Fig. 150. — Marked Induration of Tibia. — (Nichols.) 
soft tissue and periosteum. Sinuses often develop for a time, but have 



438 POSTOPERATIVE TREATMENT. 

always ultimately disappeared. They usually appear near the epiphy- 
sis, or at the junction of periosteum and shaft. As has been said, some- 
times a slight amount of cureting may be necessary before permanent 
closure takes place. It is desirable to prevent retention of infected 
material because of danger to the epiphysis and ultimate infection of 
the joint. 

The first dressing should be changed by the third day. After that 
time, dressings should be replaced sufficiently often to absorb any dis- 
charge; a wet dressing may be necessary for the first ten days. 

Marked induration along the line of the bone is frequently felt by the 
third week (Fig. 150). From that time on the bone gradually increases 
in density and size. The new shaft at first and for some months has no 
marrow canal, but is composed entirely of trabecular from periosteal bone 
with granulation tissue, instead of fat-marrow. The new shaft grows 
to be larger than the original shaft during the early months, but in time 
decreases in size and practically comes to the size of the corresponding 
shaft. In course of time a marrow canal appears in the new bone, to 
judge from the Rontgen-ray pictures. As a rule, the new shaft is a 
trifle more irregular than the original shaft. The shaft is strong enough 
to allow free use after from five to eight months. Even when the entire 
diaphysis has been removed, if the epiphyseal fine has not been inter- 
fered with, no shortening of the limb need result, and that, too, in young 
adults of fourteen years. As far as function and use go, the results 
often are absolutely perfect. Even in cases in which the epiphysis is 
interfered with, the shortening may be slight and the function perfect. 

Moorhof's Method of Treatment. — The introduction of Moorhof's 
bone wax as an artificial filling for bone cavities has created a new era 
in bone surgery, enabling the surgeon to secure better results than were 
heretofore considered possible, and practically eliminating the prolonged 
tedious after-care, so common to these cases. Moorhof's method and 
technic as described by him is as follows. (Abstract from " Journal 
of S., G. & Obs.," Vol. hi, No. 4, Mosetig-Moorhof.) 

The filling mixture which at present I employ exclusively consists 
of iodoform, spermaceti (cetaceum), and sesamoil; I call it iodoform- 
plombe, and, furthermore, temporary, as it does not permanently 
remain within the organism. This fact has caused critics to take excep- 
tion to the term "plombe." I, however, retain the term, which appears 
to me more convenient than its equivalent, "filling-mass." 

The method of preparation of the iodoform plombe is as follows: 



OSTEOMYELITIS. 439 

Strict asepsis of materials, vessels, and hands; equal parts of sperma- 
ceti and sesamoil are melted in an evaporating-dish, then filtered into a 
Florentine flask and sterilized in a water-bath; forty grams of finely 
powdered iodoform (not crystallized) are put into a sterile flask, and 
sixty grams of the hot fat mixture are added, under constant agitation. 
This agitation must be continued without interruption until the mass 
solidifies. The melting-point of the plombe is between 45 degrees and 
48 degrees Celsius. The necessity of constant agitation makes it unnec- 
essary to fill the flask; but one-fourth of its volume should be left free. 
The flask is closed with a sterile rubber stopper. Danger of decom- 
position of iodoform prevents exposure to a higher temperature. The 
proportion of iodoform may be varied, of course; but the present for- 
mula, however, has proved best. Solidified, the plombe represents a 
yellow, firm, brittle mass, in which, when carelessly prepared, the 
heavier iodoform powder lies at the bottom, while the solidified fat mass 
is above. Before using, the plombe is to be heated in a water-bath 
or suitable thermophor to a little above 50 degrees C; a higher tem- 
perature than 55 degrees is not advisable — first as regards the iodoform, 
and then to prevent the emulsion from becoming too liquid, thus retard- 
ing its cooling to below 50 degrees C, i.e., solidification, leading to 
unnecessary prolongation of the operation. Artificial promotion of 
rapid solidification by ice-bags or ether-spray is neither necessary 
nor useful. We wait patiently for a few minutes until the plombe has 
solidified up to its surface, then proceed to suture the soft parts, apply 
an occlusive dressing, and finally remove the constrictor. The flask, 
after removal from water-bath at 55 degrees C, should, of course, be 
again well shaken until poured out; for it is an emulsion. The emulsion 
has always been poured directly from the flask; it is easiest, most conven- 
ient, and serves the purpose completely. 

A corresponding preparation of the bone cavity is required before 
receiving the plombe. All diseased tissue is to be removed in a most 
painstaking and exact manner; the wall is to be cleaned thoroughly by 
gouge, sharp spoon, fraise, etc. The removal of the presenting wall 
of the cloaca takes place by angular or straight bone-chisel, or by means 
of small electric rotatory saws. Even-thing is removed down into 
sound bone. Only a complete new formation of the wall of the cavity 
guarantees asepsis. Irrigation with antiseptic solutions is not reliable. 
This, likewise, may be said of cauterization. However, irrigation 
may precede the filling, to wash away bone splinters or bone-dust when 



44° POSTOPERATIVE TREATMENT. 

a rotatory f raise has been used; a one-percent solution of formalin is 
recommended for this purpose. The operation is to be performed 
under artificial anemia, if practicable. The field of operation should 
be rendered accessible to the sight as well at to the hand ; in consequence, 
we recommend the formation of a flap from the soft parts and that 
the bone be exposed to a sufficient extent. It is understood that the 
periosteum must be kept attached to the flap of soft parts. The form 
of the cavity to be filled is of little consequence, as the semisolid filling 
penetrates everywhere; care must be taken, however, to observe the laws 
of gravity in filling, i.e., the extremity is to be placed in a corresponding 
position. In a femur, for example, with a large cavity, it is advisable 
to fill in several steps, namely, the central portion first with high eleva- 
tion, and rotation of the leg after cooling of the mass; in this place 
lowering of leg and filling of distal portion; finally, after solidification 
of the plombe above and below, conclusion of the process by filling at 
the center until cavity is obliterated. 

Not only should the cavity possess freshened aseptic walls before 
receiving the filling, but it should likewise be dry, for the least amount 
of moisture prevents a hermetic apposition of the mass, its penetration 
into every groove, fissure, and the termination of the Haversian canals, 
thus endangering the result. The presence of blood is to be considered 
first. Despite application of a constrictor it occasionally happens that 
a few drops of blood ooze from the walls constantly, although removed 
by sterile dry sponges. Moistening the sponges with adrenalin does 
not always suppress this annoying oozing. In such cases, in order to 
save time, I usually pour the filling out in such a manner as to have it 
run along one side of the wall; the plombe (owing to greater specific 
gravity) floats the drops of blood and closes the source of oozing by 
penetrating into the crevice. At the close, single drops of blood may 
be observed upon the surface of the plombe, which are easily sponged 
away after solidification. Conditions are more difficult when one is 
compelled to operate without artificial anemia ; as, for instance, in resec- 
tion of the hip or of the humerus, and also in cleaning out a marrow 
cavity high up. Circumstances here prohibit the application of a con- 
strictor. Much patience is required in these cases ; peroxid of hydrogen 
and adrenalin may be employed. Hemorrhage from severed vessels 
of the soft parts is controlled by ligation and suture ligature. This is 
to be done, if possible, before the constrictor is removed; if more volumi- 
nous soft parts have been cut, however, hemostasis after removal of 



OSTEOMYELITIS. 441 

constriction is advisable— of course, at termination of filling. This 
is covered provisionally by a piece of rubber tissue and a sterile sponge. 
These are removed after complete hemostasis of the soft parts, and the 
latter sutured. Proceeding in this way, I have never experienced a 
late hemorrhage. Short drains are employed only in joint resections, 
not elsewhere. 

The fistulous tracts that oftentimes exist suffice, as a rule, to drain 
the small amount of serous secretion from the soft parts. These tracts 
have to be curetted carefully. At times, placing of sutures at greater 
intervals insures ample drainage. 

After necrotomies the drying out of the remaining cavity, not only 
with sponges, but also by insufflation of hot or cold air until the walls 
lose their moist luster, is to be highly recommended. The hermetic 
adhesion of the filling is thereby insured. In employing the plombe 
as a filling for defects after joint resection, where the walls are not 
formed by osseous substance alone, I have always found gauze pledgets 
sufficient to dry out the cavity. 

The dressing should be applied as a permanent one. No compression 
should exist. Iodoform-gauze next to the skin is neither necessary 
nor advisable, especially not in children or in persons with tender 
skin. The appearance of eczema as a consequence of iodoform appli- 
cation to the skin of some patients is sufficiently known. The dressing 
should not be air-tight, to prevent maceration of the epidermis. Dress- 
ings applied in the vicinity of the natural openings of the body may be 
covered with a piece of batiste to prevent soiling by urine, feces, or 
wound secretions. The change of dressings should not be frequent, 
except when demanded by septic symptoms. 

The course of healing after iodoform filling is aseptic, as a rule. 
Sometimes the temperature rises within the first two or three days — 
so-called aseptic fever — which yields to a cathartic. I never employ 
plaster-of-Paris as a supportive dressing after joint resections; I rather 
apply wet organtine bandages and lathing over the permanent dressing, 
augmented eventually by a wooden gutter-splint. 

The filling of cavities without freshening up, at a late stage in the 
after-treatment, when granulations have formed, is not advisable, 
because complete asepsis cannot be supposed to be present. Filling 
should be done primarily, or not at all. 

The amount of filling employed in a given case is of no consequence, 
as the possibility of intoxication is entirely excluded. Intoxication 



44 2 POSTOPERATIVE TREATMENT. 

may occasionally occur in persons with no previously known idiosyn- 
crasy, after application of iodoform powder or liquid emulsions, because 
absorption of large quantities of iodoform by the lymphatics is possible. 
The iodoform-plombe, however, consists of a solidifying emulsion, 
influenced only by the granulations, and these are produced but slowly 
and gradually; hence rapid introduction of large amounts of iodoform 
into the circulation is impossible. The disposition of the sprouting 
granulations toward the solidified plombe varies between complete 
closure of the wound and healing by primary intention and incomplete 
closure. In the first case, absorption of the plombe is effected through 
the steadily advancing granulations by vital phenomena; in the second, 
we have partial displacement and expulsion. This ejection through 
the wound, or through previously existing fistulas enlarged by cureting, 
always takes place without suppuration, without fever, with a minimum 
of lympho-mucous secretion from the soft parts, but never from the 
filled bone cavity. Mechanical removal of the plombe, gradually 
pushing through the opening by sound, spoon, or forcible irrigation, is 
to be avoided. Clean the skin superficially, apply a fresh dressing, thus 
following Lister's teaching, "Let the wound alone." Expulsion of 
the plombe with symptoms of local sepsis — i.e., suppuration and rise 
of temperature — I have never observed. Its occurrence is hardly 
due to the fining; rather to insufficient asepsis or faulty technic. 
The method is not at fault, but the operator. In case of complete 
closure of the wound, the filling is not expelled, but absorbed by granu- 
lation. The gradual slow disappearance of the plombe can be observed 
and proven by the radioscope; one is always in a position to watch the 
course of restitution of the bone defect by organized substance winch 
eventually assumes osteoid character. After organic -cicatrization of 
the defect no shadow can be seen in the radiograph. The amount of 
time required by nature to fill the defect with osteoid substance varies, 
of course, and depends upon the character of the bony walls — if scle- 
rotic, porous, or normal — and also upon the size of the cavity. This 
question is of minor importance to the patient at the termination of 
or during cicatrization, for he may enjoy life without continuous surgical 
surveillance. It has been proven a thousand times or more on the 
living that the plombe is merely a provisional substance destined to 
prevent suppuration and its consequences. The X-ray shows the 
course of the process of healing. 

I have employed the iodoform-plombe in all fonns of osteomyelitis 



OSTKOMYKLITIS. 443 

with a chronic course; in osteom; necrotica, osteom; granulans, which 
is so painful, also in bone abscess, and in the so frequent tubercular 
form and fungus articuli. Only in the acute, infectious form of osteo- 
myelitis — the so-called "typhoid of the extremities" — is it contrain- 
dicated, because in these cases the process is still progressive. Hence 
a complete asepsis of the curetted medullary cavity it not to be obtained 
in the grave cases at least. The cavities resulting from arthrectomies 
and joint resections I likewise fill, in order to avoid suppuration. The 
cicatrix replacing the filling thus becomes firmer and more solid than 
usual; flail- joints never follow. In general, I believe that the iodoform- 
plombe can be used to advantage in all cases in which the ehmination 
of a cavity (not otherwise obtainable) is desired. 

The use of the iodoform-plombe in tuberculosis of the extremities, 
especially in joint tuberculosis of syno vial-osseous character, will 
prevent a great deal of mutilation and loss. Careful removal of the 
fungoid capsule of the joint and isolated excochleation of carious bone 
foci will yield useful members. The operative treatment of fungus 
articuli becomes thus possible, in children even, because we are able 
to preserve the epiphyseal cartilage so indispensable for further growth. 
An exception is furnished by coxitis, because here the disease itself 
usually destroys the epiphyseal cartilage, owing to its close proximity 
to the head of the femur; similar conditions may be observed in cases 
of the shoulder-joint. The operator may not replace that which already 
is destroyed; he may, however, in many cases, prevent destruction 
by the disease by his timely interference. 

In closing, I summarize as follows: 

i. Elimination of so-called "dead spaces" in operative wounds is 
always to be aimed at, to prevent suppuration and its sequelae, as well 
as to promote more rapid healing. 

2. It is appropriate to use hermetic filling of these spaces, if other 
methods cannot be employed. 

3. Conditions for filling (plombing) are as follows: 

(a) As to the Cavity. Removal of all diseased tissue, new formation 
of the cavity by ablation down into sound tissue, to produce aseptic 
conditions and render cavity dry. 

(b) As to the Filling. Preparation under aseptic precautions; the 
filling must be prepared with a permanent antiseptic, as its most impor- 
tant constituent. The mass should be poured into the cavity when 
liquid, and should solidify there to effect a hermetic closure. 



444 POSTOPERATIVE TREATMENT. 

4. The iodoform-plombe is merely a substitute; a locum-tenens 
remaining in the cavity until either entirely absorbed by granulations, 
or partially absorbed and partially expelled. 

5. Absorption or displacement takes pl^ce but slowly and gradually, 
proportionate to the production of the granulations, which serve as 
permanent organized filling. This gradual disappearance of the 
plombe keeping step with the progress of cicatrization may be observed 
radiographically. 

6 i Iodoform intoxication is not to be feared, owing to its extremely 
slow absorption and introduction into the general circulation even in 
large cavities and with a correspondingly large amount of filling material. 

7. The course of healing after use of iodoform-plombe is, with correct 
technic, always aseptic. With complete closure of the wound, healing 
prima intentione is the rule. The final results are the best possible, 
also, from a cosmetic point of view, because deeply retracted scars do 
not result, owing to the active organized substitute. 

CLUB-FOOT. 

As to Bandaging. — When a deformed foot has been corrected sur- 
gically, the first stage only of the treatment may be said to have been 
accomplished. The foot must then be fixed by plaster bandages in an 
overcorrected position. It is first evenly covered with a layer of cotton, 
and a broad bandage of canton flannel, after which the plaster band- 
ages are applied from the tips of the toes to the upper part of the thigh. 
It is important that the toes should not project beyond the bandage, 
because of the swelling that sometimes follows. It is important, also, 
that the foot should be held in the proper position while the bandage 
is hardening, and that it should not be manipulated to any extent after 
the bandage is applied, in order that no rigid wrinkle may press against 
the skin. The bandage is carried above the knee in order that the 
tibia may be rotated outward to its normal position and held there, and 
because more effective fixation can be assured and greater pressure 
exerted on the foot in walking. To utilize this pressure to better advan- 
tage the bandage should be made very thick beneath the sole, and a 
thin foot-plate of wood should be incorporated in the plaster. When 
the bandage is applied, the position of the foot should be that of over- 
correction of deformity, flexed beyond a right angle, twisted far outward, 
and the outer border should be elevated considerably beyond the level 
of the inner border. 



CLT K FOOT. 



445 



One should suppose, a fur using the force thai has been necessarily 
applied, that much pain and swelling would follow. This is, however, 
not the case. Often, on the following day, the patients are able to stand 
upon the foot, and always within the first week if the bandage has been 
properly applied. The pain following this operation is far more often 
caused by pressure of an ill-fitting bandage than by the violence that 
has been used. Thus one should be careful to remove sections of the 
bandage if it appears to cause undue discomfort. The points of dis- 
comfort are usually the front of the ankle, the back of the heel, and the 
inner border of the great toe. 

The first bandage should be re- 
moved at the end of about three 
weeks, as it will have become loose. 
The foot will then be found to be 
extremely flexible, and by an en- 
thusiast it might be considered 
cured. But knowiedge of its pre- 
vious condition should make it 
evident that a much longer time 
will be required for its consolida- 
tion in the new position. At this 
time almost no evidence of the 
operation remains, except, it may 
be, slight discoloration of the skin. 
The foot is again held as far as 
possible in the overcorrected posi- 
tion and another plaster bandage is 
applied, usually as far as the knee 

only. This remains for four weeks, or longer if it is still unbroken. 
The patient uses the foot constantly, and is drilled in the proper method 
of walking, so that the muscles of the leg may become accustomed to 
the new and normal attitudes. This second bandage is allowed to 
remain from four to six weeks. 

In some instances the deformity is now actually cured, but in the 
great majority of cases, while the foot may be normal in appearance, 
its muscular balance has not been restored. If, at this stage, treatment 
be abandoned, the deformity will invariably recur. The foot should 
be supported in the proper position, aided by massage and stimulation 
of the muscles, until the child has been able to walk firmly upon it. 




Fig. 151. — Attitude of Overcorrection 
in which the feet are flxed aeter the 
Operative Treatment. — (Whitman.) 



446 



POSTOPERATIVE TREATMENT. 



The Retention Brace. — The form of retention brace wall vary 
somewhat according to the indications of the individual case. The 
best and simplest support is the Taylor brace, the invention of Dr. C. F. 
Taylor, of New York. (Figs. 153, 154.) 

This consists essentially of a light upright that extends along the 
inner side of the leg to the knee, and a thin steel foot-plate, the exact 
size of the sole, with an upright flange on the inner side, rising to a point 
just above the dorsal surface of the foot, against which the foot is pressed 
closely so that recurrence of the varus deformity is prevented. The 





/%, 






IS 




• 


Js^* 


|VhE 


~'Wik iLi f . 


... - • ■ . -..- -.- 



Fig. 152. — Taylor Club-foot Brace. — (Whitman.) 



joint at the ankle is provided with a catch that prevents plantar flexion, 
but allows dorsal flexion. By bending the upright and the sole-plate, 
the foot may be held in slight abduction and eversion. The apparatus 
is applied with straps, as illustrated, and if necessary, its position is 
further fixed by a band of adhesive plaster, applied on the inner side of 
the leg to hold the heel firmly against the foot-plate. The foot is thus 
held constantly at a right angle to the leg, or, better, in the early stage of 
treatment, in an attitude of dorsal flexion and valgus. Occasionally 
after complete rectification of the deformity, the foot still turns in. In 



CLUB-FOOT. 



447 



most instances this is due to an inward rotation of the tibia on the femur 
at the knee-joint, but in some cases it is caused by a spiral wrist of the 
tibia itself. 

In order to correct this secondary deformity an extension of the 
upright of the brace is carried beneath the leg, provided with a joint at 
the knee, and is extended up the outer side of the thigh. At the hip it is 
attached by a free joint to a padded pelvic band of light steel. The band 
holds the upright in the proper relation to the thigh; thus, by twisting 
the part below the knee the foot can be rotated outward to the desired 
degree. In less marked cases the retention bands used for pigeon-toe 
may be employed. 





Fig. 153. Fig. 154 

Taylor club-foot brace, showing method of application and attachment. — (Whitman.) 

Methodical Manual Correction. — Several times during the day 
the brace should be removed in order that the foot may be thoroughly 
massaged and forcibly turned, first toward valgus, that is, outward at 
the mediotarsal joint so that the inner border is made convex, and then 
to the extreme limit of dorsal flexion and abduction. If the leg is rotated 
inward, it is forcibly rotated outward on the femur. Even if the tibia is 
actually twisted on its long axis, the influence of the brace and forcible 
manipulation will usually correct the deformity. Active contraction of 
the weak muscles may be induced by tickling the sole of the foot or by 
the use of electricity; and, finally, the entire limb should be thoroughly 
massaged before the brace is reapplied. 



44 8 



POSTOPERATIVE TREATMENT. 



When the deformity shows no tendency to recur, the brace may be 
removed for a part of the day; later it is used only at night, and finally it 
may be discarded if the child walks normally. But it is best to continue 
the daily manipulation, more particularly the systematic stretching or 
overcorrection of the foot, for a long time. Thus one may assure one's 
self that there is no tendency toward deformity, of which the first symp- 
tom is always a slight limitation of the range of dorsal flexion and of 
abduction. 

In some instances the deformity may have been so thoroughly over- 
corrected by the plaster-of- Paris bandage or by the brace, and the after- 





Fig. 155. Fig. 156. 

Taylor club-foot brace, showing adhesive plaster, by means of which the heel is held down, 
and the method of attachment. — {Whitman.) 



treatment of massage and stretching may have been so efficiently applied 
by the nurse or parent, that the retention brace may be unnecessary. 

On the other hand, the inclination toward deformity may be so 
marked that a brace may be necessary to hold the foot in slight abduction 
and valgus for a year longer. In other cases the use of a light brace 
to hold the foot in the overcorrected position during the night is alone 
required. These are points to be decided by the circumstances in the 
case. The period of observation and supervision is included in the 
final stage of the treatment. 

During this period the attitudes of the limb and foot of the walking 



l\! l IMS CALCANEUS. 449 

child must be carefully watched, and particularly the signs of wear on the 
sole of the shoe. If it shows greater wear on the outer side than is usual, 
it is an indication that the weight does not fall directly on the center of 
the foot, but to the outer side, and that there is therefore a tendency 
toward deformity. This must be counteracted by making the sole 
thicker on the outer side, or slightly wedge-shaped, so that the weight 
may be deflected toward the inner border. 

This third period of treatment, or rather of oversight of the func- 
tional use of the foot, must be continued indefinitely. In fact, it is 
the quality of this final supervision that decides in most instances whether 
the ultimate outcome is to be what is called a satisfactory result, or a perfect 
cure. 

TALIPES CALCANEUS. 

After-treatment. — Whatever surgical method be adopted, care 
must be taken to keep the foot in a position of somewhat marked equinus 
for at least six or eight weeks, so as to permit sound union between the 
divided ends of the tendon; even after this time great care has to be 
exercised not to put strain on it for fear of stretching the uniting structure. 
The patient should not be allowed to walk about to any extent for at 
least six months after the operation. When walking is permitted, he 
should be furnished with the apparatus here described. This consists 
of the lateral irons fitted into a surgical boot with a stop which prevents 
the joint being flexed beyond a right angle. From six weeks after 
the operation the calf should be thoroughly massaged and douched once 
or twice daily, and the faradic current applied to the muscle. 

Transplantation of Tendo-Achillis. — The other plan sometimes 
employed is not to divide the tendon at all, on account of the danger of 
subsequently stretching the uniting tissue, but to alter the bony attach- 
ment of the tendo-Achillis to the os calcis. When, owing to paralysis, 
the nutrition of the leg is faulty, and when, therefore, the union in such 
a slightly vascular structure as tendon will very probably be extremely 
imperfect, there is no doubt that a more satisfactory result will be 
obtained by altering the point of insertion of the tendo-Achillis into the 
os calcis. The great objection to this plan is, however, that the amount 
of shortening obtained by its means is comparatively limited, and the 
method is of real value only when the deformity due to talipes calcaneus 
is very moderate. 

Two operations have been recommended; in the first a flap with its 
29 



450 POSTOPERATIVE TREATMENT. 

convexity upward is raised over the heel, and dissected downward so 
as to expose the whole of the posterior part of the os calcis. A saw is then 
applied to the upper surface of the bone immediately in front of the 
tendon, and, by a vertical cut, a thin slice of the bone, with the .attached 
tendo-Achillis, is sawed off. This slice of bone is pulled down until the 
insertion of the tendon is at a point as low as may be necessary, or as 
low as possible, and the bone is fixed into its new position by two or 
three small screws or nails. The projecting lower portion of the slice 
of bone is then cut off so as to make it level with the under surface of the 
os calcis. 

In some cases in which the tendon is very long it has been advised 
that the upper part of the bone thus sawed off should be turned round 
at a right angle and applied to a raw surface made by cutting off suffi- 
cient of the under surface of the os calcis ; this is done to bring down the 
insertion of the tendon to the lowest possible point. The results of 
attempts to produce great shortening in this manner do not, however, 
seem to be very satisfactory. 

After-treatment. — After the operation the wound is stitched up 
without a drainage-tube, the usual antiseptic dressings are applied, and 
the foot is put upon a splint so that the toes are markedly pointed, and 
are kept in that position for about six weeks, until bony union is com- 
plete. After that time the patient may be allowed to walk about with 
the boot already described. 

OSTEOTOMY FOR CURVED TIBIA AND FIBULA. 

After-treatment. — According to Cheyne-Burghard, the limb should 
be put on a splint, and for this purpose we generally employ a trough 
of Gooch's or Day's veneer flannel or kid-lined splinting, for the first 
few days, until the wound has healed and the stitches are removed. 
This trough is cut of sufficient breadth to surround rather more than 
half the limb, and to extend from the fold of the buttock, where it is 
cut away obliquely from within outward and upward, to well below 
the foot. A portion of the splint should be cut out opposite the heel 
so that no injurious pressure shall be exerted, but in quite small children 
this need not be done; instead, the padding may be so arranged that the 
heel is pushed somewhat forward and at the same time does not press 
upon the splint. The limb is made to fit the splint exactly by means 
of a number of pads of suitable size and shape, packed in on each side 



OSTEOTOMY FOR CURVED TIBIA AND FIBULA. 



451 



and below the limb, which may thus be fixed in any position that is 
most suitable. It is well to place a special pad over the front of the 
knee and leg, and by graduating the padding any desired amount of 
inversion or eversion of the foot can be obtained; generally speaking, 
a large, long pad should be applied opposite the point of greatest con- 
vexity of the curve that it is required to obliterate, and smaller, thicker 
ones between the ends of the bones and the side of the splint. The 
latter is then fastened round the limb by broad bandages, and the 




Fig. 157. — Dr. Chas. F. Stillman's Long Bow-leg Brace. 



whole is laid upon an inclined plane to which it may be secured by one 
or two strips of bandage. 

In about a week or ten days the splint may be undone, the stitches 
removed, and a collodion dressing applied. Any additional correction 
of the deformity may then be made, if necessary, under an anesthetic, 
and the limb put up in the fully rectified position in a plaster-of-Paris 
or silicate of potash bandage and left for about six weeks for union to 
occur; it is, of course, necessary that the foot should be strictly at a 
right angle. In six weeks' time the old bandage may be taken off and 
a fresh one applied for a similar period, when the union should be 



45 2 



POSTOPERATIVE TREATMENT. 



thoroughly firm, after which a Stillman's long or short brace should now 
be applied and worn for several months (see Fig. 157). 

This apparatus exerts a constant spring force, which tends to over- 
come or prevent deformity. It is adjustable by means of rachets and 
a key, and is very effective, for not only does it support the limb while 
the deformity is being reduced, but the rachets at the lower extremity 

of the instrument allow the surgeon to control 
the position of the feet at the same time. 

The short brace is worn only below the knee, 
and is intended merely for cases in which the 
curvature is slight or entirely below the knee. 

OSTEOTOMY FOR GENU VALGUM. 

After-treatment. — Cheyne states that after 
the completion of the operation one or two 
sutures should be inserted, an antiseptic dress- 
ing applied, the limb brought straight and put 
upon a suitable splint, which we are accustomed 
to make from a roll of Gooch's or Day's splint- 
ing properly padded. If an ordinary straight 
splint is used, it is well to cut away a space 
for the heel so as to obviate all fear of pressure 
upon the os calcis. In applying the padding 
special care must be taken to have a large 
pad over the internal condyle, and others over 
the outer side of the foot and ankle, so as to 
press the leg inward and keep it in good posi- 
tion. Another special pad must be placed in 
front of the knee so as to prevent flexion at the joint. 

After the splint has been applied the limb should be laid upon an 
inclined plane. In about a week or ten days the dressing may be taken 
off, the stitches removed, a collodion dressing applied, and the limb 
put up in a plaster-of-Paris or silicate bandage. In small children, 
and in any case in which there is much curvature of the femur, it is 
well to continue the bandage up around the pelvis, otherwise the 
casing may fail to get a sufficient hold upon the thigh. After about 
six weeks union will generally be firm and the splint may be left off, 
but the child should be kept in bed for two or three weeks longer, 




Fig. 158. — Outside Irons 
for Use after Opera- 
tion for Genu Valgum 
in Adults. — {Erichsen.) 



OSTEOTOMY FOR GENU VALGUM, 453 

and allowed gradually to recover the full range of movement in the 
knee. 

During this time the leg should be massaged and rubbed, so as to 
improve the circulation and the tone of the muscles. Walking may be 
permitted in about ten weeks, and, should the rachitic condition of the 
bone have completely passed off, no further apparatus will be required. 
When the osteotomy has been done upon a young adult in whom there 
is some doubt as to whether the bones have become firmly consolidated, 
it is well for the patient, after operation, to wear one or other of the 
forms of apparatus which are usually employed to exert mechanical 
pressure upon the deformity. This generally consists of an outside 
iron fastened to the pelvis above and the heel of the boot below, and 
furnished with hinges opposite the hip-joint, knee-joint, and ankle- 
joint (see Fig. 158). There is also generally a band or sling which 
tends to draw the knee outward against the iron. This apparatus can 
be made of quite light material, and should be worn for two or three 
months after operation. 

Should genu valgum occur after excision of the knee, the choice will 
lie between a fresh excision or Macewen's operation; in most cases 
the latter is less severe and is an equally satisfactory method. Should 
genu valgum occur in connection with infantile paralysis, the usefulness 
of the limb will have to be taken into consideration; in some cases it 
may be best to perform excision of the knee-joint, so as to give the patient 
a firm and fixed point of support, while in others in which the muscles 
are fairly healthy, a Macewen's operation, or any of the other opera- 
tive procedures which we have mentioned, may be employed. (Cheyne.) 



CHAPTER XIX. 

VALUE OF RONTGEN-RAY IN POSTOPERA- 
TIVE TREATMENT; MANNER OF 
APPLICATION. 



CHAPTER XIX. 

VALUE OF RONTGEN-RAYIN POSTOPERATIVE TREATMENT; 
MANNER OF APPLICATION. 

RONTGEN-RAY THERAPY. 

General Considerations. — Since the discovery of the therapeutic 
value of the Rontgen-rays in certain forms of chronic skin diseases a 
large number of medical men have been engaged in testing the effects 
or determining the value of these rays by actual clinical demonstrations 
upon various forms of malignant growths, the result being that, while 
the curability of the large, deep-seated, hard, and especially internal 
cancers, is still a matter of impossibility by means of any apparatus 
yet devised, there can be no doubt that superficial cancers, especially 
the epitheliomas and the softer varieties of mammary cancer, and some 
forms of tuberculous enlargements, are curable by this means, yet the fact 
remains that even in these cases the cure in the majority of instances is 
more quickly and more satisfactorily accomplished by operative measures. 

The experience of the author, which has been somewhat extensive, 
fully agrees with the statement already advanced by Leonard, Lund 
and others, and, in fact, now generally conceded by unbiased observers, 
that the Rontgen-rays should not be employed, as a rule, as a preliminary 
method of treatment except in cases distinctively inoperable, or when 
cosmetic effects are desired, and life is not threatened by delay. 

It has also been the author's experience that even in cases of epithelial 
cancer, the application of escharotics, in case the patient refuses other 
operative treatment, as a preliminary measure, often proves highly bene- 
ficial, and increases greatly the therapeutic action of the Rontgen-ray, 
and shortens greatly the time required for treatment. In all other cases 
of any magnitude surgical treatment should always precede the appli- 
cation of the rays. It would be manifestly absurd to attack by radiother- 
apy a large scirrhous cancer of the breast, the removal of which, even 
if possible by this means, would require many months of treatment, 
when an equally favorable, if not better, result would be obtained in the 
course of a few days by extirpation. Again, the liability of flooding the 

457 



458 POSTOPERATIVE TREATMENT. 

system with toxins by causing rapid destruction and absorption of cancer 
tissue or growths of low vitality has not by any means been exaggerated. 
When insisting upon Rontgen-ray treatment, the patient should be informed 
upon this subject. 

Dosage and Method of Treatment. — Many writes affirm that the 
source of electric energy and choice of apparatus are of secondary impor- 
tance, provided a proper tube is used, the static machine or the coil 
giving equally good therapeutic results. In the author's opinion, 
nothing could be more fallacious or misleading. Familiarity with and 
constant use of both forms of apparatus have convinced me that the 
larger coils are far more valuable in Rontgen-ray therapy, and only by 
their use may we expect in the future greater success and more perman- 
ent effects than are now supposed to be possible. This country is flooded 
with cheap static machines and other apparatus, and many failures are 
due to the employment of inadequate dosage. In the treatment of 
malignant growths I have long since abandoned the use of the ponder- 
ous glass static machine. Rontgen-ray dosage is just as important in 
Rontgen-ray therapy as the action or knowledge of drugs in physical 
ailments, and when Rontgen-ray administration can be so regulated as 
to produce certain effects in all cases, scientific dosage can then be de- 
termined upon. All tubes should be carefully tested as to penetration. 

The degree of vacuum in a Crookes tube is more accurately deter- 
mined by the internal resistance of the tube than in any other way. 
You will determine this by connecting to the terminals of the exciting 
apparatus without having spark gaps in series; then by bringing the 
discharge rods or other conductors connected to the prime conductors 
within a short distance of each other, a point will be reached where the 
current will pass between the discharge rods rather than through the 
tube. If the resistance of the tube be low, the spark gap will be short,, 
whereas, if the resistance of the tube be high, the spark gap will be longer 
in proportion to the degree of vacuum. 

In making this test as to the degree of vacuum, a spark gap should 
not be used in series with the tube, because a spark gap sets up an induc- 
tive action which produces a counter-electromotive force in the stems 
of the tubes supporting the terminals, and would cause additional resist- 
ance on this account. For example, a tube that will back up a spark 
gap of one-half inch without spark gaps in series should back up only an 
inch and a half with two one-half inch spark gaps in series with the tube, 
but it will be .found that with the spark gap in series the tube will back 



PLATE Y. 




Postoperative Keloid Growth or Tumor Following an Operation for 
Abscess of Right Kidney. 

Growth removed bv the combined use of escharotics and X-rav. 



V \l ll OF RONTGEN-RAY. 461 

up a much longer spark gap than an inch and a half, showing that the 
counter-electromotive force developed in the stems or metal terminals 
of the tube is quite great. This varies according to the construction 
of the tube. The use of auxiliary anodes greatly overcomes this factor, 
so that tubes of different types vary in this respect. The tube with 
the least internal resistance for a given degree of vacuum is undoubtedly 
the best for both Rontgen-ray and therapeutic purposes. (Wagner.) 

In applying the Rontgen-ray treatment the technic is simple, but sub- 
ject to great modifications according to the experience of the operator, 
nature and extent of the growth, idiosyncrasies of the patient, and variety 
as well as penetration of the tube used. The duration of exposure and 
the distance of the tube from the field vary considerably, and a knowledge 
of these can be obtained only by actual experiment. 

The distance of the tube from the parts treated must vary at times 
from 3 to 10 inches, and the time of exposure varies from five to fifteen 
minutes. It is the author's custom to commence treatment with the 
tube at a distance of 10 to 12 inches, gradually decreasing the distance 
as the patient becomes accustomed to its effects, or the parts treated 
indicate closer or stronger application. As to the frequency of treat- 
ment, much depends upon the effect produced or noticed. Daily treat- 
ment is frequently necessary at first; later, once or twice a week will 
usually prove sufficient. In dealing with morbid growths, there is a 
strong probability that the rays act cumulatively; therefore, if signs of 
dermatitis or erythema appear, the treatment should be suspended until 
they have subsided. If the effects of the Rontgen-ray treatment are 
pronounced, the length of time of exposure during treatment should be 
lessened, or the tube moved farther from the part treated, extreme care 
being necessary to prevent overstimulation of the absorbents. Should 
this condition of overstimulation occur, all beneficial action may sud- 
denly cease, and further treatment will have to be suspended until, by 
rest, the circulation of the parts improves and the tissues and absor- 
bents return to their normal condition. 

Some writers contend that no effect is noticeable upon the deep- 
seated carcinomatous disease until reaction of the tissues about the 
growth occurs. They therefore aim to use a high- vacuum tube with an 
amount of penetration sufficient to produce this reaction quickly. There 
can be no question that this theory is correct. The absorbents should 
be stimulated, but, as before stated, should never be overstimulated, 
for if stimulated beyond their capacity, negative results must follow. 



462 



POSTOPERATIVE TREATMENT. 



Exposures for deep-seated, malignant growth should, therefore, not be 
given oftener than two or three times a week, commencing with five- to 
ten-minute exposures, and increasing the length of time according to the 
effects produced upon the affected part. 

Effects of Treatment. — The claims made for Rontgen-ray treat- 
ment in surface malignant growths of all types are summed up as follows 
by Morton: (1) Relief from excruciating pain and constant suffering; 
{2) reduction in size of growth; (3) establishment of process of repair; 

(4) removal of odor if present; (5) the 
cessation of the discharge; (6) softening 
and disappearance of lymphatic nodes; 
(7) disappearance of lymphatic nodes not 
directly submitted to treatment, and often 
quite distant; (8) removal of cachectic 
color and appearance of the skin; (9) im- 
provement in general health; (10) cure of 
many undoubtedly malignant growths, 
confirmed by absence of relapse after 
many months of observation. 

The results obtained from the rays for 
postoperative recurrence or in inoper- 
able cases are shown in a paper written 
by Holding.* He reports 148 cases col- 
lected from literature, with four of his 
own in addition. A study of these cases 
shows that 32 percent were apparently 
cured, 58 percent were improved, and 
only 10 percent unimproved. As noted 
before, the most favorable results were obtained in cases of superficial 
growth, such as epithelioma of the face and mammary carcinoma. 

Of the six cases reported by Pusey of intraabdominal cancer, the 
result was unfavorable in every instance. Turner reports (London 
"Lancet") 18 cases of inoperable recurrent malignant disease. Marked 
improvement was shown in all, but the best results were obtained in the 
mammary cases. He also noted diminution of pain, loosening of adhe- 
sions, and relief from contracting and tightening sensation. 

Bryant reports cases of recurrent or inoperable cancer of the rectum 
which were amenable to Rontgen-ray treatment. 

* " Albany Medical Annals," Feb., 1903. 




Fig. 159. — Rontgen-ray Tube 
with Vacuum Control. 



VALUE OF RONTGEN-RAY. 



463 



Roswell Park," in an article upon the subject, concludes as follows: 
The Rontgen-rays afford a method of treatment for extremely new 
growths of limited area and superficial character which, while not exectly 
certain, is extremely promising. They not only cause no pain, but tend 
to relieve pain, both superficial and deep, in a most satisfactory manner. 
They are adapted to cases which can hardly be submitted to any other 
method of treatment, and they afford more hope in recurrent, delayed, 




GUNDELACH TUBE WITH HEAVY ANODE. 



or inoperable cases, than any other method of treatment. More than 
this, the rays afford a supplementary method of treatment after opera- 
tion, by which the benefits of the same may be enhanced and enlarged. 
Character and Kind of Tube. — The majority of observers agree 
that for the treatment of superficial growths, soft tubes or tubes of low 
resistance are preferred; and for deeper growths, hard tubes or those 




Fig. 161. — Hard-rubber Mask. 

of high resistance are necessary. The ordinary tubes have such change- 
able vacuums that they are unsuited for Rontgen-ray therapy, and only 
those tubes which permit perfect control of the vacuum should be em- 
ployed (Fig. 159). 

The author prefers high- vacuum tubes because they give good results 
in the treatment of the deeper tissue, not affected by low- vacuum tubes, 
*"Med. News," May 30, 1903. 



464 



POSTOPERATIVE TREATMENT. 




i 



VALUE OF RONTGEN-RAY. 465 

while the high-vacuum tubes give equally as good, if not better, results 




Fig. 163. — Showing Manner of Applying the Rontgen-rays to Tuberculous 

Knee. 

in the treatment of superficial conditions, provided a little longer exposure 
is made. 

The author prefers for su- 
perficial work the ordinary C 
" Gold-Medal" or Wagner's 
adjustable focus tube (Fig. 
162); for deep penetration, 

the improved large-sized R. 

1 ° Fig. 164. — Caldwell Tube. 

F. universal regulating tube 

(or Gundelach heavy anode tubes) (Fig. 160). 

3° 




4 66 



POSTOPERATIVE TREATMENT. 



For rectal and vaginal treatment, the Caldwell tube is preferable (see 
Fig. 164). These tubes are made with a water-jacket and the cathode 





Fig. i6= 



Fig. 166. 





Fig. 167. Fig. 168. 

Types of Epithelioma Cured by Roxtgen-ray Treatment. 



so arranged that the main direction of the Rontgen-rays emitted is at 
an angle to the axis of the tube, the anode being : grounded. It is intro- 



VALUE OF RONTGEN-R AY. 467 

duced within the vagina, and a Pennington brass shield is used if it is 
desired to limit the area of radiance. Owing to the fact that the tube is 
brought in close contact with the parts under treatment, the duration 
of exposure must be lessened in accordance therewith. 

Manner of Protecting the Patient. — In place of the cumbersome 
lead screens heretofore employed, the author uses a hard-rubber mask 
(see Fig. 161). 

The Friedlander protectiYe shield, although somewhat heavier, is 
equally efficacious. It not only protects the patient, but also the eyes 
of the operator, and admits of easy adjustment of the rays. 



CHAPTER XX. 

COMPENSATIVE OR ARTIFICIAL 
APPLIANCES. 



CHAPTER XX. 
COMPENSATIVE OR ARTIFICIAL APPLIANCES. 

Where and How to Amputate. — L. E. Jepson states that for many 
years efforts have been made to construct a substitute for the natural 
limb, or to restore, in a measure at least, the functional uses of the ampu- 
tated member. While great advance has undoubtedly been made 
and the work of the ingenious inventor greatly appreciated by patients, 
nevertheless the results will be far more satisfactory and gratifying 
when the operating surgeon realizes the necessity of working more in 
harmony with the prosthetist. This matter has already been referred to 
briefly on page 404, but as there seems to be so very little reference to 
this subject in our modern text-books, we deem it advisable to present 
the views of an authority upon this interesting subject. 

The anatomic facts regarding conditions of amputations requiring 
investigation may be summarized by the enumeration of certain diffi- 
culties experienced in a large majority of the amputations of the leg 
at any point below the junction of the middle and lower third, or the 
"point of election" (nine to ten inches below the knee). 

The following are such difficulties: 

(A) In a Lisfranc, tarsometatarsal or — 

(B) A Chopart, mediotarsal amputation, the equilibrium of 
the tarsals forming the arch is destroyed, becoming simply a heap of 
angular fragments and almost invariably producing pressures and 
irritations, causing severe pain from its use. In a tarsometatarsal or 
a mediotarsal amputation the tendo-Achillis almost always contracts 
to such an extent as to pull the heel up and the amputated surface down, 
thereby elongating the stump and making necessary an artificial leg 
which will not touch the end, and the use of an elevated sole on the other 
foot to counteract the extra length. In a mediotarsal amputation the 
astragalus is v^ry liable to become displaced from its intermalleolar 
position causing serious trouble. 

(C) A tibiotarsal amputation (Pirogoff or Syme) at the anklc- 
joint, even with the most favorable results, which are seldom secured, 
necessitates a large and cumbersome appliance about the ankle, and, 

47i 



472 



POSTOPERATIVE TREATMENT. 



moreover, seldom gives comfort or satisfaction to the wearer. With 
the foregoing amputations it is many times mechanically impossible to 
secure a satisfactory fit and adjustment for prosthetic apparatus. 

(D) In amputations oe the leg between the " point of election" 
and the ankle it was observed and noted that the healing process was 
long and stubborn, while a certain percentage of such cases absolutely 
refused to heal in a satisfactory manner. It was further noted that 
almost invariably the stump was extremely sensitive to heat, cold, and 
the touch, and also subject to swelling, ulceration, and abscess. It 
was again noted that the patient usually elevated the stump to the highest 




Fig. 169. — Chop art Amputation. 



Fig. 170. — Syme's Amputation 
at Ankle-joint. 



position in sitting or reclining, the same procedure being followed by 
those wearing artificial legs, thereby reducing the swelling and relieving 
the throbbing, bursting, and painful feeling of the extremity. It was 
inferred that these difficulties were the result of deficient circulation, 
and an anatomic investigation confirmed the theory and established 
the fact. At about the middle of the mid-third and in the foot the 
collateral circulation is found to be complete, but between these two 
points there is very little collateral circulation. It therefore follows 
that the extremity of a stump made by amputating between these two 
points is practically devoid of circulation, the blood simply stagnating in 



COMPENSATIVE OR ARTIFICIAL Al'IM.I AXC'I S. 473 

the end, resulting in a swollen, inflammatory condition which nature 
tries to relieve by ulceration and abscess. The most satisfactory place 
of amputation below the knee is the middle of the mid-third, and at 
this point the best results are secured from a prosthetic point of view. 

(E) Amputation of the leg higher than the junction of the upper 
and the middle thirds detracts from the use of the stump in throwing the 
leg forward in walking. In these amputations, especially those made 
just below or near the head of the fibula, it was observed that the lower 
end of the fibula was a constant source of trouble in wearing an artificial 
leg. The stump becomes more and more atrophied by wearing an 
artificial leg, and the more the shrinkage, the more prominent the fibula. 
The trouble is caused by this lower end of the fibula rotating outward 
and coming in contact with the socket of the artificial leg, often resulting 
in periostitis and almost invariably in an enlarged, sore, and irritable 
condition and extremely sensitive to the touch. Many times it has 
been absolutely necessary to have it removed before an artificial leg 
could be worn with, any degree of comfort. In the present advanced 
state of surgery it is no more of a major operation, while the amputa- 
tion is being made, to remove the fibula. The objections against re- 
moving the fibula entire are more theoretical than practical, being 
mainly that the leverage might be somewhat lessened by taking out 
the head of the fibula, also the very slight risk of opening the knee-joint. 

A single longitudinal incision on the outer side of the fibula 
exposes the bone. The periosteum being carefully separated and the 
bone separated from its ligamentous attachment can be removed with- 
out destroying the action of the external hamstring or biceps tendon. 
While this tendon is inserted into the head of fibula it also embraces 
the external lateral ligament of the knee-joint, and has a strong attach- 
ment to the outer tuberosity of the tibia. The short fibula has no func- 
tion whatever, and at the best makes an ill-shaped stump and its removal 
obviates all difficulties. Although this may be considered an innova- 
tion, yet experience warrants the statement that in these short amputa- 
tions it should ahvays be removed. 

(F) Amputations at the knee as formerly made often resulted in 
tender, irritable, and sensitive stumps; but with a proper amputation, 
they are most useful and satisfactory. In such cases the end of the 
femur must not be disturbed, the condyles untrimmed, and the cicatrices 
carried high from the end with posterior flaps. If the patella is unin- 
jured, an experienced and skilful surgeon may, under favorable cir- 



474 POSTOPERATIVE TREATMENT. 

cumstances, successfully bring it down over the end of the femur and 
place it in the depression between the condyles ; nevertheless, from our 
experience, we believe it is better to remove it, for whenever the patella 
withdraws from the intercondylar notch it presents serious difficulties 
in wearing an artificial leg. 

(G) Amputations of the thigh made too close to the knee do 
not leave room for the artificial knee. The amputation should be made 
three or four inches above the knee. Whenever it is necessary to ampu- 
tate higher than the junction of the middle with the lower third, every 
inch possible, and consistent with a good flap, should be saved. 

(H) The position of the cicatrix, it was also found by practical 
observation in fitting limbs, had much to do with the comfort of the 
patient in wearing limbs. The cicatrix should never come over the 
end or anterior part of the stump. If a long anterior flap is used the 
cicatrix can fall posteriorly. The position of the scar has been largely 
changed to accommodate the artificial limb. 

(I) The bone should be sacrificed to the perfection of the flap 
if the amputation is to be made below the middle of the mid-third. If 
the amputation is to be made above the middle of the mid-third the 
perfection of the flap should be sacrificed to the length of the bone. To 
secure leverage, every inch above the middle of the mid-third should 
be saved. 

(J) Postoperative Condition of Nerves. — One of the most 
serious defects in amputating was found to result from leaving the nerves 
exposed too near the extremity, resulting in an irritable and painful 
condition, and often resulting in neuroma. It has been necessary to 
advise many patients to undergo an operation to correct the results of 
ignorance of this fact in amputation. 

(K) Postoperative Conditions of Bone. — It was also observed 
that serious results followed the leaving of sharp edges and corners of 
bone, which, upon attempting to apply an artificial leg, caused tender, 
irritable, and sore places, the bone at times actually piercing the skin. 
All edges and sharp corners should be well rounded off. 

(L) Redundant tissue on the end of the stump is a positive detri- 
ment, and produces evil results by easily becoming inflamed and tender. 
The extremities should be well covered, but nothing more. 

(M) The Size of the Stump. — It was found that in most cases, as 
the result of improper treatment, the stump had been allowed to become 
abnormally large. There is a tendency with most stumps soon after 



COMPKXSATIYK OR \RHIHI\I. A I'M I A \( I ;S. 



475 



healing to take on adipose tissue, thereby becoming large, soft, and 
flabby. Many surgeons seem to believe that an attenuated stump was 
a misfortune. This has been one of the greatest errors and most preva- 
lent evils that have had to be met and overcome. It is an established 
fact that any stump when left to itself will become hypertrophied, and 
by wearing an artificial leg will become atrophied. It is therefore 





Fig. 171. — Shows Construction of 
Artificial Limb ; for Amputation 
Six Inches below the Knee. 



Fig. 172. — One of the Late Devices, 
Double Socket Artificial Limb; 
for Amputation below the Knee. 
Improved Felt Foot. 



wise to minimize the shrinkage of the stump as the result of wearing an 
artificial leg, and thereby minimize the necessary changes in the socket 
to counteract such shrinkage. It was further found that in most cases 
of attempted treatment the stump was imperfectly prepared at the best. 
The old method was to bandage tightly, retarding the circulation, 
producing uneven shrinkage and affording no protection from accident. 



476 



POSTOPERATIVE TREATMENT. 



Again, whenever a stubborn hypertrophied stump failed to yield to 
bandages it was thought necessary to apply a temporary artificial leg 
in order to reduce the stump, which was done at the inconvenience and 
expense of the wearer. This method was everywhere prevalent and 
among all manufacturers. In the place of the bandage and temporary 
artificial leg there has now been substituted a leather corset, lacing 
about the stump and producing by its firm and evenly distributed pres- 
sure rapid and uniform shrinkage, giving a conical shape, which is 
greatly to be desired, and all this has been done without interfering 
with the circulation. This treatment also affords a most perfect pro- 
tection against injury from accident. 

General Remarks. — The artificial leg must be as light as possible, 
but should be of sufficient weight to assure the wearer sufficient strength 





Fig. 173. — Improved Sponge Rubber 
Foot, with Ankle-joint. 



Fig. 174. — Showing Mexican Felt 
Foot with Ankle-joint. 



not only to carry the weight of the body, but to withstand the require- 
ments of his occupation. By the use of the best-grade material, skill, 
and painstaking workmanship, the limb may be made exceptionally 
light in weight and also strong and durable (see Figs. 171, 172). 

Some prefer the rubber foot. It cannot be made as light, however, 
as a willow, wood, or felt boot. 

The location or the weight in an artificial leg has much to 
do with its seeming heaviness ; thus, two legs made for the same person, 
each weighing five pounds, one may feel very heavy and the other light. 
A leg with a light upper part and a heavy foot would be called a heavy 
leg, and a leg with a heavy upper part and a fight foot would be pro- 
nounced a light leg. 

The majority of artificial legs are worn by the laboring classes, their 



COMPENSATIVE OR ARTIFICIAL APPLIANCES. 477 

occupation subjecting them to more frequent injury. Comparatively 
few are financially able to purchase a duplicate artificial leg, hence the 
leg should be made as strong and durable as possible, that repairs and 
loss of time may be avoided, and due consideration should be given in 
selecting and purchasing an artificial limb. 

Children requiring artificial limbs should be fitted so soon as possible; 
as early as the fourth or fifth year they may be adjusted and worn with 
comfort. Adjustable limbs adapted for the growing child have now 
been perfected and are quite satisfactory. The most graceful and easy 
walkers are those who commence the use of the artificial leg in youth, 
and by the time they are grown it has become second nature to wear a 
leg. 

How to Prepare a Stump for an Artificial Limb. — It is of great 
importance that the stump be prepared before being fitted into an 
artificial leg. This is accomplished ordinarily by keeping the stump 
tightly bandaged from the time it is sufficiently healed until the artificial 
leg is w^orn. Bandage from the end of the stump to the knee if the 
amputation is below, or to the body if the amputation is above, the knee. 

The tight bandage seems to solidify and tighten the stump, w r hich 
otherwise becomes soft and flabby. Some of the manufacturers prefer 
the leather corset, claiming that it is better, holds the limb in position 
more firmly, is more easily applied, and is far more comfortable to the 
wearer, and also tends to give the stump the desired conical shape. 

The corset should be w^orn either next to the stump over a well-fitted 
stump stocking or a thickness of the underclothing, according to the 
preference of the wearer. It should be w r orn continuously day and 
night, and adjusted as tightly as possible without causing undue dis- 
comfort. 

If the amputation has been made below the knee, the knee-joint 
should be exercised and straightened as much as possible to prevent 
flexion or ankylosis. Applications of electricity and massage may 
frequently be used to advantage. 

Artificial Hands and Arms. — Despite the unwarranted and exag- 
gerated statements of certain manufacturers, no artificial hand or arm 
has yet been devised that equals in benefit artificial legs, nor is this 
possible in case both arms have been amputated above the elbow, 
owing to the many complicated uses of an artificial hand. 

In double amputations of the arms the greatest benefit in wearing 
artificial arms is the improvement in appearances, although the wearer 



478 



POSTOPERATIVE TREATMENT. 



may, in the course of time, accomplish considerable along the lines of 
helpfulness. 

A valise or heavy object can be carried, the weight coming on the 
shoulder-pad. In case but one arm has been amputated, however, 
the natural hand may be of great assistance, enabling the artificial arm 
to assume various flexed positions, and, owing to the arrangements of 

the shoulder-straps, the artificial hand may 
likewise be of great assistance to the natural. 
Many laboring men prefer a simple hook, and 
great utility may be derived in wearing such a 
contrivance. The rubber hand is preferred by 
many, for the reason that it possesses a flesh- 
like softness. The fingers and thumb may be 
bent or placed in the desired position with the 
natural hand, and they will remain in this posi- 
tion until rearranged. The artificial hand may 
be thus arranged and controlled by a button 
or spring enabling them to hold a knife, fork, 
brush, etc. 

Fig. 175 illustrates one of the latest and 
most complete devices or substitutes for an 
artificial hand. By pressing a button at (a) 
the hand can be taken off, and the knife, fork, 
brush, or hook or any other instrument can be 
inserted in the end of the wrist as well as the 
palm of the hand. The spring controlled by 
the button (a) retains the tools in the end of the 
wrist, while the spring controlled by the button (d) retains tools in the 
palm of the hand. The hand and wrist attachments are the same for 
all amputations. When manual work is required, the hand is removed 
and the hook inserted in the forearm (see Fig. 175). 




Fig. 175. — Substitute por 
Artificial Hand. 



CHAPTER XXI. 
POSTOPERATIVE DIETETICS. 



CHAPTER XXL 
POSTOPERATIVE DIETETICS. 

The feeding of patients after operation is one of the very important 
elements in after-treatment. The effect of food itself, as food, is prob- 
ably a minor factor as compared with the complications it may produce, 
largely in a mechanical way, when injudiciously administered. Chief 
among these are nausea and its frequent successor, vomiting, either 
of which may result later in serious deprivation of food which the patient 
urgently requires. The latter not only more effectually than nausea 
prevents the taking of food, but also adds the element of physical strain, 
with the possible opening of wounds, contamination of operative sites, 
and the general hindrance of reparative and recuperative processes 
throughout the body. 

Postoperative feeding depends to some extent upon the plan adopted 
in preparing the patient for .the operation, but is so largely a matter by 
itself that the former may for practical purposes be disregarded. Suffice 
it to say that modern methods of preparation, which have shown the 
fallacy of the older belief in pronounced starvation as a preliminary, 
now leave the patient in a much better physical and mental condition 
to imdergo the deprivation of food absolutely necessary after surgical 
intervention. By judicious feeding before operation, in all but emer- 
gency cases, much can be done to prevent postoperative shock and allied 
conditions, the presence of which markedly interferes with the resump- 
tion of nourishment. This question has been discussed in the chapter 
on preparation, and the statements made need not here be repeated. 

General Rules for Postoperative Feeding. — As a rule, regardless 
of nausea or vomiting, no food should be given a patient by the mouth 
during the first eighteen hours after operation, though circumstances 
may render advisable departure in either direction from this time limit. 
In the presence of positive indications, a previously well-nourished 
adult may safely go without food for two or even three days ; on the con- 
trary, either very young or old and exhausted persons must not for a 
long time be deprived of nourishment. Fortunately, both the last- 
named groups are relatively free from the disagreeable effects of anes- 
3 i 481 



4S2 POSTOPERATIVE TREATMENT. 

thesia, and often retain food that is given as early as eight to twelve 
hours after operation. A number of surgeons guard against postopera- 
tive nausea, and thus favor the early retention of food, by washing the 
stomach with warm water, until the latter returns clear, by means of a 
stomach-tube introduced while the patient is still upon the operating 
table. I have previously mentioned tins expedient as a preventive of 
shock and postoperative thirst in all major operations: surgeons who 
do not adopt this as a routine procedure may well employ it with patients 
whose stomachs have been specially rebellious before operation. Per- 
sons profoundly exhausted before operation may soon after require nutri- 
ent enemas at regular intervals; in some of these cases a stimulant and 
nutritive combination of beef-tea, white of egg, and brandy may be placed 
high in the intestine before the patient leaves the operating room. 
Patients in whom operation has not involved the abdomen usually will 
tolerate feeding earlier than those in whom the peritoneum has been dis- 
turbed. 

If, then, in ordinary cases at the end of eighteen hours the stomach 
has for some time been perfectly quiet, the fluid which has been given 
to allay thirst may be made to include, or be entirely changed to, liquid 
nourishment. This must be given in spoonful doses only, even- one or 
two hours, until the retaining power of the stomach is tested. The 
proper beginning of food depends so largely upon the condition of the 
individual patient that any time limit is in a sense arbitrary; as an aid 
in this matter a careful, observing, and experienced nurse is at this 
period invaluable. One of the principal objections advanced by Hans 
Kehr against operating in private houses is the meddlesome in- 
terference of the family with the after-feeding of the patient. In the 
absence of a trained nurse in particular, but in even* case in general, 
the surgeon must keep himself informed regarding even- detail of the 
patient "s behavior and must give definite orders when to begin feeding 
and what the food is to be. Should vomiting be provoked by the hrst 
trial, all fluids must be withheld for two or three hours; Vichy water 
may then be given. Under these circumstances McKay is partial to 
Semmola's glycerin drink, made by adding 1 ounce of glycerin and 3c 
grains of citric acid to 1 pint of water: this is useful from the beginning 
in allaying thirst. Albumin-water, made by straining the beaten whites 
of eggs, or better draining off the fluid part after it has stood for an hour, 
diluting three or four times with water, and adding sugar and lemon- 
juice, is an ideal substance with which to begin the feeding of patients. 



POSTOPERATIVE DIETETICS. 483 

It is bettor not to inform them what they are getting, as the thought of 
raw egg may render the mixture distasteful. The albumin-water 
should be freshly made every six hours, though in cold weather it may 
be kept at least twice this length of time. At the end of thirty or thirty- 
six hours the albumin-water may be substituted by peptonized milk, 
not carried to the point of bitterness, milk and Vichy, milk and lime- 
water, or a clear broth. One part milk, 2 parts cream, and 2 parts 
lime- water is a mixture that agrees with some persons. Given at first 
in spoonful doses, either may, if well borne, soon be increased to 1 or 2 
ounces every two hours. Idiosyncrasy of the patient has much to do in 
determining the selection of the earlier diet-list. Perhaps of no substance 
is this more true than of milk, and before giving it, inquiry should be 
made as to w r hether it agreed with the patient during health. On the 
third day soft foods may be begun, and two days later be followed by 
light solids; at the end of a week ordinary diet may be resumed. 

Diet for Laparotomy Patients. — After employing liquid nourish- 
ment in increasing amounts and at lengthened intervals for two or three 
days the patient may be given light soft foods selected from a list includ- 
ing oyster soup, junket, chicken jelly, various forms of gruel, etc. Two 
days later there may be added chicken or mutton broth with rice or 
barley, poached or very soft-boiled eggs, dry or milk- toast, oysters, and other 
soft foods. With patients who present no disturbing stomach condi- 
tions after operation it is wise early to discard liquid diet, as it has a 
tendency, especially in such persons, to cause an annoying degree of 
flatus. After four or five days McKay* finds gelatin blanc-mange a 
most acceptable food, and makes a routine practice of giving it to his 
section cases. He prefers the following formula: Of 1 quart of fresh 
milk, place \\ pints in a double-lined saucepan. Soak 1 "quart" 
packet of gelatin in the remaining \ pint of milk for two hours. Then 
stir this milk and gelatin into the milk in the saucepan, now brought to 
the boiling-point, and add 2 dessertspoonfuls of sugar and a little flavor- 
ing. After three minutes remove the saucepan from the fire and add to 
the contents the white of one egg, which has been beaten to a froth. 
Now T turn the whole into a shape previously cooled in cold water, allow 
the contents to set, and place the shape either in a cool place or in an ice- 
chest. By the end of a week the diet may include fish, eggs, oysters, 
squab, chicken, sweetbreads, custards, puddings, and the like. In 
uncomplicated cases ordinary diet may be resumed by the tenth or 
*"The Preparation and After-treatment of Section Cases," London, 1905. 



484 POSTOPERATIVE TREATMENT. ; • 

twelfth day. Vegetables should be given sparingly, or better not at all, 
before this time. This statement, unless in exceptional cases, applies 
also to fruits, although the juice of oranges and lemons may be taken 
much earlier. 

Diet After Operations Upon the Stomach. — Competent surgeons 
vary greatly regarding the time at which to begin feeding after opera- 
tion upon the stomach. Some allow milk by the mouth on the following 
day, others wait four to eight days, nourishment in the meanwhile being 
supplied by rectal feeding. As a routine it is better to supply food in the 
shape of enemas, if they be tolerated, for at least two days after stomach 
operations of any magnitude. Feeding by the mouth may then be 
begun as previously indicated for section cases in general. More care 
and a longer time are required, however, in increasing the quantity 
and in passing to the more substantial materials. The heavier solids 
should not be allowed until the beginning of the fourth week. When 
a gastric fistula is made, fluids may be given very soon after operation. 
Several days should be taken in returning to semisolids, and two or three 
weeks to solids, if they are masticated by the patient before introduction. 

Diet After Operation Upon the Intestine. — As examples of the general 
principles to be followed in these cases may be cited the directions of 
Deaver and of Kelly in their recent works on appendicitis. The former 
says: "No nourishment should be given by the mouth until the lapse 
of at least twenty-four hours after the operation. If at the expiration 
of this time the stomach has for some hours showed no evidence of irrita- 
bility, albumin- water, one of the commercial preparations of beef, or a 
meat broth prepared by the nurse, or milk, peptonized by the cold proc- 
ess and the peptonization not carried so far as to render the milk bitter, 
in doses of a teaspoonful (or less) may be given if the stomach remains 
tolerant. Milk with lime-water may be used in place of the peptonized 
milk, and may be cautiously given every hour or tw T o. A dram or so of 
whisky may also be given if required. If the stomach continues reten- 
tive, larger quantities of milk may soon be given — 1 to 2 ounces every 
two hours — and the quantity increased or decreased according to circum- 
stances, and the intervals lengthened as convalescence progresses. In 
addition to milk, chicken broth, bouillon, liquid beef peptonoids, beef 
peptones, dry champagne, etc., may be administered. If vomiting 
should return, absolute abstinence from food and liquids, for a time 
at least, will again become necessary." Kelly states that "all nourish- 
ment should be suspended after the operation until the stomach is settled. 



POSTOPERATIVE DIETETICS. 485 

The first food given should be egg-albumen, prepared by beating the 
whites of 4 eggs to a froth and allowing it to stand in a cool place for an 
hour or more, when the liquid (about 50 c. c.) can be drained off, 
leaving the frothy part behind. It is best to give a teaspoonful at a 
time mixed in 2 or 3 tablespoonfuls of cold water with a little sugar and 
5 or 10 drops of lemon-juice. It may also be given in ginger ale, in 
orange-juice, or in sherry wine. About the third or fourth day soft 
food may be given, and after the first week a stronger diet may be gradu- 
ally resumed. As a rule, attendants are overanxious to feed patients, 
who can often stand absolute starvation for four or five days very well." 
In cases of intestinal resection, feeding must be almost wholly by enemas 
for one week. During that time the desire of the patient for something 
by the mouth may be partially satisfied by giving 1 or 2 ounces of liquid 
food at four- or six-hour intervals. At the end of the week semifluid 
and later soft foods maybe given by the mouth. Particular care should 
be taken to aA r oid materials that leave a large residue in the intestine. 

Diet after operations about the gallbladder, pancreas, or kidney 
is in general that prescribed for laparotomy cases, but, in addition, 
certain precautions applicable to each may profitably be observed. When 
bile is draining externally or the pancreatic secretion is diminished, the 
exhibition of fats should be limited. The employment of specially 
digested foods is usually not necessary. When one or both kidneys 
have been operated upon, a diet approximating that found useful in 
cases of nephritis may be of service in relieving stress upon the weakened 
organ. Articles of diet commonly given in nonoperated affections of 
these organs will readily suggest themselves to the surgeon. 

Diet After Operations About the Mouth. — Many patients who 
have undergone operation involving the mouth, especially young children 
who have had a cleft palate or harelip repaired, and older people who 
have had cancer of the lip, jaw, or tongue removed, tolerate food very 
soon after recovering from the anesthetic. Milk, preferably sterilized 
for a day or two, is the most desirable food, and usually may be begun 
with but little preHminary trial of blander fluids. Beef-juice is advan- 
tageous in some cases. The problem here is chiefly one of mechanics, 
how safely to get the food by the wound. To most patients it may be 
given by a spoon, being therewith placed far back on the tongue. In 
some instances a glass feeding-tube connected with a funnel holding the 
food gives greater satisfaction; a pinchcock must be arranged to secure 
absolute control of the fluid. Feeding should for some days not be 



486 POSTOPERATIVE TREATMENT. 

entrusted to the patient himself, even an adult, or to an untrained assis- 
tant; only an experienced nurse is competent properly to administer 
food in such cases. In special instances feeding will have to be accom- 
plished through a nasal tube or even by the rectum. It must be remem- 
bered that suture wounds about the mouth are usually under consider- 
able tension and are inherently liable to separate; hence the necessity 
for extra precautions to prevent unnecessary movement of the parts. 

Diet After Operations About the Head. — The chief indication here, 
especially if the brain has been disturbed, is to supply a diet that is light 
and easily digested and nonirritating in even' way ; the last point applies 
particularly to the circulatory system. Alcohol, except on the strongest 
positive indications, as in case of persons habitually using it, should not 
be administered. Liquid diet should be the rule for several days in 
severe cases, followed by a similar period of soft foods, the heavier 
solids being omitted until convalescence is well established. If the 
patient is partially or entirely unconscious, feeding by nasal or stomach- 
tube or even by nutrient enemas may be necessary. 

The Use of Alcohol After Operations. — As among physicians 
in treating medical cases, widely divergent opinions are held by surgeons 
regarding the employment of alcohol after operation. Not a few give 
it in some form, as wine, whisky, or even brandy, practically as a routine 
measure. Disregarding entirely the temperance aspect of the question, 
I do not believe this general use is demanded or even advisable. Well- 
nourished persons previously unaccustomed to alcohol do not require it 
after uncomplicated operations. The rule should be not to give alcohol; 
to this exceptions may be made as indicated. Patients in profound 
shock, those exhausted by long illness or even by acute, rapidly wasting 
diseases, who can take or at least absorb but little food after operation, 
may well be given the supporting effect of alcohol as a temporary expe- 
dient until food can be assimilated; in such cases the alcohol should be 
discontinued at the earliest possible moment. In cases of profuse 
suppuration, and especially in septicemia, alcohol is most valuable. To 
persons accustomed to its use, especially in large quantities, it must be 
supplied after operation, the amount to be regulated by the demand 
based upon the previous consumption of the drug. 

Feeding by Nutrient Enemas. — This should be accomplished by 
means of a rectal tube or large catheter gently inserted into the bowel 
as high as possible — at least 8 to 12 inches. If practicable, the patient 
should he on his side, with the buttocks slightly elevated. The food is 



POSTOPERATIVE DEETET* S. 4S7 

introduced through a funnel or fountain syringe by gravity, never by 
mean? of a piston syringe. The temperature of the food should be 
from 92° to Q4\ The amount should not exceed 8 ounces, and in many 
instances 4 or 6 will be better retained. Peptonized milk, milk and 
beaten eggs, milk-peptone, starch or sugar and milk, or other similar 
combinations may be employed. Many surgeons add a fourth or half 
ounce of vane or a small quantity of whisky. In cases when, soon after 
operation, stimulation rather than nourishment is desired, enemas of 
salt solution and hot black coffee are particularly efficacious. If the 
rectum is irritable, a preparation of opium given with, or just preceding, 
the enema will aid in its retention. Enemas should be given four, five 
or six hours apart. Even* twenty-four hours, or even oftener in some 
instances, the bowels should be thoroughly cleansed by copious high 
injections of saline solution; in rare cases, this maybe advisable before 
each nutrient enema. 



INDEX. 



Abdomen, preparation of, for operation, 10 
author's summary, 16 
Kelly's method, 10 
Martin's method, 3 
Morris' method, 15 
Senn's method, 12 
Abdominal irrigator, Blake, 72 

section (see Laparotomy), 227 
Abscess, appendicular, 239 

multiple, following appen- 

dicectomy, 239 
Senn's method of drainage, 
254 
drainage and postoperative treat- 
ment, 320 
kidney, 275 
liver, 208 

Rhoades' method of treat- 
ment, 208 
postoperative treatment and 
drainage, 208 
mastoid, drainage after, 182 
ovarian (see Pyosalpinx), 251 
pelvic, general considerations, 251 
postoperative treatment, 

251 
psoas, general remarks on after- 
treatment, 321 
Treves' method of treat- 
ment, 321 
Barker's method of treat- 
ment, 323 
pulmonary (see Empyema) 

postoperative treatment, 
320 
retrorectal, postoperative treat- 
ment, 321 
stitch, MacDonald's method of 
prevention, n 
Adhesions, postoperative, after abdominal 
section, 232 
methods of pre- 
vention, 233 
Cargile mem- 
brane in, 232 
following brain 
operations, 

J 53 
Harris' method 
of prevention, 
153 



Adjuncts to postoperative treatment, 113 
Alcohol, use of, after operations, 486 
Alexander's operation, postoperative treat- 
ment, 272 
Alimentation, postoperative — 
rectal, 117 

special formula for, 119 
subcutaneous feeding, 120 
See also under Dietetics. 
Amputations, general considerations, 389 

normal or ideal operation, 393 
periosteum, value in, 391 
postoperative complications, 

399 
atrophy of muscles, 395 
changes in bone, 401 
changes in nerves, 401 
conical stumps, 400 
faulty stumps, 397 
painful stumps, 400 
postoperative treatment in 

general, 397 
author's method of 

bandaging in septic 

cases, 398 
removal of dressings, 

397 
removal of ligatures, 

398 
removal of stitches, 

398 
usual form of dress- 
ing, 397 
partial amputations, 3 
septic, open method of treat- 
ment, 399 
typical methods, .395 
Amputations, special — 

breast, after-treatment in gen- 
eral, 189 
author's method, 191 
Bodine's triangular splint 

in, 189 
changing of dressings, 

etc., 189 
dressing, usual form, iSg 
Murphy's, 190 
fingers and thumb, after-treat- 
ment, 406 
foot and toes, 408 

Chopart's partial, 409 



489 



49° 



INDEX. 



Amputations, special. — 

foot and toes, Hey's, 409 

Lisfranc's partial, 409 
subastragaloid, 410 
hip-joint, Wyeth's method, 403 
postoperative treatment, 
403 
thigh, closed method of treating 
flaps, 405 
open method of treat- 
ment, 405 
Andrews' (E. Wyllys) method in hernia, 257 
Andrews' (Frank T.) suture scissors, 102 
Anemia, treatment of, 2 
Anesthesia — 

dilatation of stomach 

after, 94 
hematemesis, 42 
shock from, 92 
pallor and feebleness of pulse 

after, 80 
postoperative effects in general, 

79 
postoperative nausea and vomit- 
ing, 83 
methods of prevention, 
84 
postoperative thirst, 95 
posture of patient after, 80 
Ankle-joint, resection of, 426 
Antiseptic dressings, character of, 30 
fomentation, 103 
gauzes in general, 30 
irrigation after abdominal sec- 
tion, 16 
wound treatment, 10 1 
Appendicectomy — 

Brewer's method of after-treat- 
ment, 241 
fecal fistula after, 243 
general remarks concerning 

postoperative treatment, 238 
multiple abscess following, 239 
Ochsner's method of after-care, 

241 
ventral hernia after, 243 
Arndt's treatment of intestinal paresis, 46 
Arteries, ligation of, 319 
Artificial limbs, general remarks concern- 
ing, 471 

Bandage, Barton's modified, 120 

Elizabeth Trotter's abdominal, 
127 

for lower jaw, 127 

Gibson's, 120 

Martin's abdominal, 121 

modified Velpeau, 126 

Randolph's, 121 

roller, methods of applying, 122 
Bandaging, 120 
Bed, Crosby's invalid, 130 
fracture -bed, 128 



Bed, Moore's chair or commode, 130 

Munger's, 129 
Bed-lift, Jane way's, 132 

Michael Reese Hospital, 130 
Bed-sores, 75 
Biliary fistula, 207 

Bladder, preparatory treatment for opera- 
tion, 275 
cystitis, postoperative, 55 
cystotomy, perineal, postoperative 

treatment, 283 
cystotomy, suprapubic, 276 

special method of drainage 
in, 281 
Block's method in cholecystostomy, 202 
Blood, Blaud's pill for, 2 

pressure, apparatus for determin- 
ing, 88 
value of, 87 
Bodine's triangular splint, 189 
Bones, postoperative hemorrhage from, 40 
Horsley's wax in, 40 
osteomyelitis, chronic, 433 
Brain, preparation for cerebral operations 
(Keen), 14 
hernia of, 151 

surgery, Harris' method of prevent- 
ing adhesions in, 153 
Breast, amputation of, 189 

methods of bandaging after, 189 
author's, 191 
Bodine's, 189 
Murphy's, 190 
Brewer on appendicectomy, 241 

on bandaging, 120 
Bronchitis, postoperative (see Pneumonia), 

47 
Bubo, postoperative treatment, 324 
Hayden's method, 325 
Krulle's method, 324 

Calcium chlorid, use of, in jaundice, 64 
Carbolic acid, gangrene caused by, 54 
Cargile membrane — 

use of, in skin-grafting, 146 
in brain surgery, 153 
to prevent postoperative 
intestinal adhesions, 
232 
Castration, remarks concerning, 311 

postoperative treatment, 313 
Cerebral operations (see Operations on 

Brain), 150 
Cervix uteri, preparation for operation, 9 

operations for laceration of, 
272 
after-care, removal [of 
sutures, etc., 273 
Christie's (Robert J., Jr.) method of drain- 
age in empyema, 185 
Cholecystotomy, after-treatment of, general, 
206 
Block's operation, 202 



INDEX. 



49 1 



Cholecystectomy, Cook's method of drain- 
age in, 204 
general consideration of, 

201 
Kehr's method of drain- 
age in, 201 
Mayo Robson's method. 

207 
Morrison's method of 
drainage in, 202 
Cholecystenterostomy, Murphy's button 

in, 203 
Circumcision, Cheyne's method of after- 
care, 314 
method of Bransford Lewis, 

315 
Cleft palate, after-treatment in general, 162 
complications following oper- 
ations, 162 
failure of union, causes 
and treatment of, 163 
postoperative hemor- 
rhage, treatment of, 
162, 163 
secondary operation in, 164 
Treves' method of after-treat- 
ment, 164 
Club-foot, after-treatment in general, 444 
methodical manual correction 

of, 447 
talipes calcaneus, 449 
talipes varus or equino- varus, 444 
Taylor's retention brace, 446 
transplantation of tendo-Achillis, 

449 
Collapse, postoperative (see Surgical Shock), 

85 

Colostomy, general remarks, 217 

after-treatment in general, 219 
for acute intestinal obstruction, 

221 
Martin's method of rapid, 221 
Treves' method in ; 219 

Compensative appliances, 471 

Compound fractures — 

after-treatment in general, 356 
complications during repair of, 

373 
ankylosis of joints, 377 
atrophy of muscles, 377 
delirium, 373 
edema, 373 
emphysema, 373 
fat embolism, 375 
gangrene of limb, 376 
necrosis of bone in, 378 
osteomyelitis, 374 
paralysis, 377 
pneumonia, 374 
pyemia, 376 
septicemia, 376 
thrombosis, 376 
irrigation in, 357 



Compound fractures — 

modern treatment of, Nicholas 

Senn, 353 
nonunion after, 378 
of long bones,shortening af ter,382 
special, 

arm or forearm, dress- 
ing and postoperative 
treatment, 366 
leg, Buck's extension ap- 
paratus in, 361 
patella, 379 

skull, comminuted frac- 
ture, postoperative 
treatment, 359 
thigh, 367 

after-treatment in 

general, 367 
ambulatory splint 

in, 369 
in childhood, 369 
Cook's method of drainage in surgery of 

gallbladder, 206 
Cystitis, postoperative, cause and treat- 
ment, 55 
Cystotomy, perineal method, 283 

drainage in the postoperative 

treatment, 283 
suprapubic, general remarks 
on, 276 
Stevenson's drainage-tube 

for, 281 
Treves' after-treatment, 279 

DaCosta (J. Chalmers) on treatment of 

infected wounds, 106 
Delirium, postoperative, causes of and treat- 
ment, 63 
from absorption of 
iodoform, 63 
Depilatory, author's formula for, 16 

use of, by Robert Morris, 15 
Diarrhea, postoperative, causes of and 

treatment, 35 
Dietetics, postoperative — 

general rules regarding diet, 487 
diet for laparotomy patients, 483 
diet after operation on gallblad- 
der, 485 
head, 486 
intestines, 484 
mouth, 485 
stomach, 484 
Drainage, general consideration of, 29 
material used in, 254 

capillary drainage, how 

and when used, 254 
combined tubular and 

capillary, 255 
Mikulicz iodoform, 256 
Morris wick, 255 
tubular, glass, rubber, 
etc., 254 



492 



INDEX. 



Drainage, ordinary wounds, 29 

remarks on, by Joseph Price, 16 
by Nicholas Senn, 254 
Dressings, antiseptic gauze, 31 

essentials requisite for good, 30 
D wight (E. W.) method of abdominal 
flushing in peritonitis, 71 

EiiBOLiSii, postoperative, 51 
Empyema (or pleurotomy), 183 

Bryants method of drainage, 187 
Christie's method of drainage 

in, 185 
cleaning of lung cavity, Schede's 

method, 184 
dangers attending irrigation of 

cavity, 184 
Hutton's method of drainage in, 

184 
method of securing mobility 

after, 184 
postoperative treatment in gen- 
eral, 183 
Senn's method of drainage in-, 
185 
Enemata, nutrient, 118, 199 

special formula for, 119 
purgative, 45 
Enterostomy, postoperative — 
diet following, 223 
indications for, 223 
"WitzePs method of, 223 
Epididymis, erasion of, 312 
Epithelioma, X-ray treatment of, 466 
Erysipelas, general symptoms of, 64 
general treatment of, 66 
Henry's treatment with carbolic 

acid, 66 
Kraske's method of scarifica- 
tion in, 66 
local treatment, 66, 67 
phlegmonous types of, 67 
serum in antistreptococcic, 66 
special drainage and treatment 
of, 67 
Esophagotomy, Davis apparatus for, 179 

method of feeding after, 

open treatment of incision, 

180 
postoperative treatment in 
general, 179 
Excision of joints, 413 

ankle-joint, postoperative treat- 
ment of, 426 
elbow-joint, postoperative treat- 
ment, 416 
general remarks on, 413 
knee-joint, after-treatment, 423 
Cheyne's method of after- 
treatment, 424 
shoulder-joint, after-treatment, 
4i4 



Excision of joints — 

shoulder-joint, Treves' method 

of treatment, 415 
summary' of postoperative treat- 
ment, 427 

Fever, postoperative — 

causes of, 35 

treatment of, 35 
Field of operation (see Preparation 0} Pa- 
tients), 7 
Fingers, amputation of, 406 
Fistula, postoperative — 

biliary, causes and treatment of, 
207 

fecal, following appendicectomy, 

243 
following intestinal operations, 

224 
in ano, postoperative treatment, 
open method, 300 
elastic ligature method, 

301 
method of Grant, 300 
Fowler's (George R.) semi-erect position, 

81 
Fractures, compound (vide Compound 
Fractures), 353 
complications following, 373 
shortening following, 382 

Gallbladder operations — 

Cook's method of drainage in, 

204 
Kehr's method of drainage in, 

204 
Morrison's method of drainage 

in, 202 
postoperative treatment in gen- 
eral, 201 
Mayo Robson's method, 

Gangrene, following operations on extremi- 
ties, 54 
from carbolic acid, 54 
treatment of, 55 
Gant (S. G.) treatment of fistula in ano, 

300 _ 
Gasserian ganglion — 

after-care and treatment, 325 
excision of, 325 

prevention of postoperative 
shock in, 327 
Gastroenterostomy, after-care and treat- 
ment, 202 
Gastrostomy, feeding after, 214 

method of after-treatment, 
213 
Gastrotomy, general remarks on, 213 
Gauze (see Dressings), 31 
Genu valgum, treatment after osteotomy, 

45 2 
Goiter (vide Thyroid Gland), 180 



INDEX. 



493 



Granulations, healing of wounds by, 139 

Outten's method of stimulation, 
139 

Hare (Hobart Amorv) on bandaging in 

postoperative work, 121 
Hare-lip, after-treatment in general, 167 

Lister's method of treatment, 167 
care of infants after opera- 
tion, 168 
feeding after, 168 
Harris (M. L.) on prevention of adhesions 

in brain surgery, 153 
Hayden's method of treating bubo, 325 
Hematemesis, 42 

treatment of, 43 
Hemophilia, 40 

Hemorrhage, after operations on tongue, 41 
cause and treatment of, 40 
from bones, 40 
Horsley's wax in, 40 
in jaundiced patients, 64 

Ruspini's styptic for, 
64 
in nasal operations, 41 

method of controlling, 
4i 
postoperative, 39 
Hemorrhoids, after-treatment in general, 

293 
clamp and cautery method, 

after-treatment of, 294 
complications following 

operations, 296 
crushing method, 296 

abscess and fistula, 

296 
hemorrhage, 296 
ulceration, 283 
ligature method, 293 

postoperative treat- 
ment, 293 
Henry (F. P.) on carbolic acid in erysip- 
elas, 66 
Hepatic ducts (vide Gallbladder Opera- 
tions), 194 
toxemia, 211 
Hernia, cerebral, 151 

complications following operation, 
261 
Andrews' (E.Wyllys) method, 

257 
general postoperative treatment, 

259 
method of bandaging after opera- 
tion, 257 
postoperative, 263 

causes of, 264 
radical cure of, 265 
umbilical, Mavo's after-treatment, 

266 
ventral, following appendicectomy, 
postoperative treatment of, 243 



Hip, amputation of, 403 

postoperative treatment of, 403 
Horsley's aseptic wax in hemorrhage from 

bones, 40 
Hutchinson's (Jonathan, Jr.) treatment of 

wounds, 105 
Hutton's method of drainage in empyema, 

184 
Hydrocele, open method of treatment of, 

3*4 

Hypodermatoclysis — 

indications for use of, 113 
intravenous, 115 

Halsted's formula for 

solution, 113 
Kelly's apparatus for, 

114 
Locke's formula for, 113 
manner of administration of, 

temperature of solution in, 114 
Hypospadias (or ectopia vesicae), general 
considerations, 330 
postoperative treatment, 330 
Hysterectomy, technic and after-treatment, 
269 

Icterus, calcium chlorid in, 64 
postoperative, 63 

preliminary treatment of patients 
afflicted with, 203 
Ileus, postoperative, 43 

prevention of, 44 
treatment of, 44 

Arndt's method, 
46 
Infection, postoperative — 

character of, 37 

general consideration of, 

36 
symptoms of, 37 
treatment of, 38 
of wounds, antiseptic irrigation 

°r"> 337 
DaCosta's method of 

treatment of, 106 
open method of treat- 
ment of, 369 
Pryor's method of treat- 
ment of, after plastic 
operations, 105 
Injections (see Enemata) 
Insanity, postoperative, causes and treat- 
ment of, 62 
clinical history of, 62 
Intestines — 

obstruction of, acute, 222 
colostomy for, 2 1 7 
enterostomy in, 223 
feeding after, 223 
fistula following, 224 
symptoms of shock in, 
222 



494 



INDEX. 



Intestines — 

operations in general, 215 

Murphy's button in, 215 
postoperative adhesions, 232 
prevention of, 233 
Intravenous injections — 

general remarks on, 115 
normal salt solution for, 117 
Spencer-Collins apparatus for, 

Intubation, as a postoperative measure, 
176 
method of feeding after, 179 
O'Dwyer's instruments for, 179 
removal of tube, 178 

Inunctions, leaf lard in anemia, 2, 120 

Jacob's retention tube or catheter, 242 
Janeway's bed-lift, 132 

sphygmomanometer, 88 
Jaundice, postoperative — 
causes of, 63 
treatment of, 63 

Mayo Robson's method 
of, 64 
postoperative capillarv oozing, 

63 
Jaw, resection of lower, 156 
resection of upper, 155 
after-treatment, 156 
Jerome (J. X.) on rectal alimentation, 117 
Joints, excision of, 413 
results, 427 
resection of ankle, 426 
hip, 420 
knee, 423 
wrist, 418 
tuberculosis of, treatment of, 335 

Keen's preparation of patient for cerebral 
operations, 14 
method of trephining, 152 
Kehr's drainage of gallbladder, 204 
KeUy (Howard A.)— 

apparatus for hypodermatocly- 

sis, 114 
on postoperative treatment of 

ovariotomy, 243 
on postoperative treatment of 

perineorrhaphy, 289 
on preparation of patient for 
laparotomy, 9 
Kidneys, abscess of, 275 

after-treatment in general, 

2 75 
nephrectomy, 274 
nephrorrhaphy, 274 
nephrotomy, 273 
Knee, excision of, 423 
Kocher (Theodor) on amputations, 389 
on excision of joints, 413 
on postoperative treatment of 
granulating wounds, 139 



Kocher (Theodor) operation for excision of 
tongue, 160 
method of after-treat- 
ment, 160 
Kraske's method of extirpation of rectum, 
298 
scarification in erysipelas, 66 

LAMiXECTOiTY, after-treatment in general, 
328 
closure of wound, 328 
posture of patient, 328 
Thorburn's method in, 328 
Laparotomy, general considerations, 227 

author's method of closing 
abdominal wound, 21 

drainage in septic cases, 228 

dry method of treatment, 21 

Gruzdeff 's method of abdom- 
inal flushing, 227 

Kocher's method for septic 
conditions, 229 

McBurney's method in septic 
cases, 231 

method of Franklin H. Mar- 
tin, 229 

position of incision, 230 

postoperative treatment, Kel- 
ly's method, 243 

Price (Joseph) on drainage 
after, 17 

Treves' method of after-treat- 
ment of. 234 
Laryngotomy, 173 

after-treatment in general, 

173 
method of feeding after, 176 
Lister (Lord), postoperative treatment of 

hare-lip, 167 
Litholapaxy, postoperative treatment in gen- 
eral, 281 
Keegan's method, 282 
Thompson's (Sir Henry) meth- 
od of after-treatment, 282 
Lithotomy, perineal method, 283 

drainage after, 283 
suprapubic method, 276 
Liver, abscess of, 208 

Rhoades' method and after- 
treatment of, 208 
acute fatty degeneration of, 211 
general remarks, 197 
Lungs, empyema (or pleurotomy) , drainage 
and postoperative treatment, 183 
postoperative pneumonia, 47 

Mania, postoperative, 62 
Many-tailed bandage, 127 
Martin (Franklin H.) — 

after-treatment of laparotomy, 

229 
fixed dressings after laparotomy, 
229 



INDEX. 



495 



Martin (Franklin II.) — 

on perineorrhaphy, 286 
preparation of patient, 3 
rapid colostomy for acute ob- 
struction, 221 

Massage, medico-mechanical apparatus for, 

133 
Mastoid bone — 

abscess of, 182 

complications following 

operation, 183 
drainage of, 183 
open method of treat- 
ment, 182 
Barker's point in trephining, 183 
Maxilla, inferior, excision of, 156 

Treves' method of after- 
treatment, 156 
superior, excision of, 155 

postoperative treatment, 

155 
Mayo brothers on modification of Maun- 
sell's method of extirpation 
of rectum, 299 
on preparation of patients for 

stomach operations, 8 
on removal of varicose veins, ^^t, 
Mayo Robson on after-treatment of chol- 
ecystotomy, 207 
on calcium chlorid in jaun- 
dice, 64 
McBumey's (Charles) laparotomy for sep- 
tic conditions, 219 
Mesenteric vessels, thrombosis of, 51 
Mikulicz drain, 256 

Morphin, postoperative indications for, 97 
Morris (Robt. T.), depilatory, preference 
for, 15 
on capillary drainage, 

255 
preparation of patients 
for operation, 15 
Morrison's method of drainage in cholecys- 

totomy, 202 
Mouth, sterilization of, for operation, 8 

Miller's formula for, 8 
Moynihan's after-treatment of prostatec- 
tomy, 306 
Mucous surfaces, disinfection of, 15 
Murphy (J. B.)— 

on intestinal anastomosis, 215 
indications for use of but- 
ton in, 215 
length of time button is re- 
tained, 216 
postoperative treatment, 

215 
on treatment of general peri- 
tonitis, 72 
on vaginal extirpation of rec- 
tum, 298 
Myxedema following operation on thyroid 
gland, 182 



Nausea and vomiting following anesthesia, 

83 

methods of prevention and 
treatment, 84 
Neck, operations on, 173 

posture of patient after operation, 

173 
tracheotomy, laryngotomy, etc., 173 
Nephrectomy, after-treatment in general, 

274 
Nephrotomy, general remarks, 273 
Neurasthenia, postoperative, 58 
Nichols (E. H.) on treatment of chronic 

osteomyelitis, 434 
Nose, subcutaneous injections of paraffin 
for flat nose, 168 
Eckstein's method, 168 

postoperative effects, 168 
Gersuny's paraffin ointment, 168 
treatment of postoperative infection, 
169 
Nutrient enemata (vide Rectal Alimenta- 
tion), 118, 199 

Ochsner (A. J.) — 

on preparation of patient for 

operation, 15 
on treatment of appendicitis, 
241 
method of rectal feeding, 
241 
Osteomyelitis, chronic, Nichol's method of 
treatment, 434 
Moorhof's method, 438 
Osteotomy, for curvature of tibia and 
fibula, 450 
for genu valgum, 452 
Outten (W. B.) on healing of granulated 
surfaces, 139 
after-care and treat- 
ment, 140 
goldbeater's skin in, 
140 
Ovariotomy, Howard Kelly's method of 
after-treatment, 243 
care of bowels in, 248 
dietetics in, 245 
dressing of abdominal 

wound, 249 
removal of sutures, 

250 
special diet-lists, 245 
toilet of patient, 244 
postoperative complications, 
irritability of bladder 
after, 246 
temperature, elevation 
of, 248 
remarks on convalescence, 250 

Pain, indications for the use of morphin, 97 
Palate, cleft, Cheyne's method of after- 
treatment, 162 



496 



INDEX. 



Palate, cleft, complications following oper- 
ation, 162 
failure of union, 163 
hemorrhage, 163 
shock, 162 
results of operation, 166 
Treves' method of after- 
treatment, 159 
Pallor, postoperative, significance of, 80 

treatment of, 80 
Paraffin, subcutaneous injection of, in flat 
nose, 168 
postoperative treatment, 169 
Paresis, intestinal — 

Arndt's method of treatment, 46 
pseudo-ileus, postoperative, 43 
illustrative case of, 44 
symptoms of, 44 
treatment in general, 45 
Wiggin's method of treatment, 
46 
Patella, fracture of, 379 

expectant method of treatment, 

380 _ 
operative method of treatment, 

381 

postoperative treatment, 381 
restoration of function, 381 « 
Pelvic abscess, method of drainage, 251 

postoperative treatment, 251 
Perineal lithotomy, 283 
Perineorrhaphy, Martin's technic, 286 

postoperative ' treatment, 

286 
Kelly's method of post- 
operative treatment, 289 
Peritonitis, postoperative — 

antiseptic irrigation in, 69 
author's summary of treatment 

of, 74 
choice of incision for, 69 
cocain anesthesia in serious 

cases of, 68 
D wight's method of flushing in, 

7i 
importance of lavage in, 62 
Murphy's method, 72 
open method of treatment with 

continuous irrigation, 69 
posture of patient in, 68 
Senn's method of drainage, 254 
toilet of peritoneal cavity in, 69 
topical applications in, 68 

Pneumonia, postoperative, 47 

Postanesthetic complications (see under 
Anesthesia) — 

Postoperative complications — 
bed-sores, 75 
cystitis, 55 
delirium, 63 
diarrhea, 35 
erysipelas, 64 
gangrene, 54 



Postoperative complications — 

hematemesis, 42 

hemorrhage, 39 

ileus or paresis, 43 

infection, 36 

insanity, 62 

jaundice, 63 

neurasthenia, 58 

peritonitis, 67 

pneumonia, 48 

surgical shock, 85 

thirst, 95 

thrombosis, 51 
Posture of patient, after anesthesia, impor- 
tance of, 80 
after neck operations, 173 
after stomach opera- 
tions, 202 
in peritonitis, 68 
Preparation of field of operation — ■ 

abdominal operations, 3, 4, 9, 11 

bladder and kidneys, 9 

cerebral, Keen's method, 14 

cervix and uterus, 9 

eye, 8 

field in general, Nicholas Senn, 
11 

general remarks, 7 

mouth, nose, and throat, 8 

skin, 8 

stomach, 8 
Preparation of patients for operation — 

author's summary, 16 

general remarks, 1 

method of Howard Kelly, 9 

method of Franklin H. Martin, 3 

method of Robert Morris, 15 

method of A. J. Ochsner, 15 

method of Joseph Price, 4 

method of Nicholas Senn, 11 

method of Sir Frederick Treves, 
6 
Price (Joseph) on postoperative drainage, 

17 

remarks on preparation of 
patients for operation, 5, 
11 

solutions for peritoneal cav- 
ity, 16 

use of sterile gauze, 17 
Prostatectomy, postoperative treatment, 306 

Ferguson's method, 308 

Fenwick's (E. Hurry) method, 

3°7 
Moynihan's method, 306 
perineal method, 308 
supiapubic method of, 306 
Prosthetic or compensative appliances, gen- 
eral remarks on, 471 
Pseudo-ileus, postoperative (see Intestinal 

Paresis), 43 
Pulse as an indication of septic absorption, 
37 



INDEX. 



497 



Purgative enemata, 45 
Purgatives after laparotomy, 4 

Kelly's purgative mixtures, 2 
use of, prior to operation on 
abdomen, 2 
Pyemia, symptoms of, 36 
treatment of, 38 
Pylorectomy, leakage of gastric juice after, 

215 
postoperative treatment, 214 
Pyosalpinx, after-treatment in general, 251 

drainage after, 254 

Rectal feeding, alcohol in, 118, 199 

blood in, defibrinated, 118 
formula for enemata, 120 
meat-extract in, 118 
milk in, 118 
normal salt solution for, 

119 
Philadelphia Hospital for- 
mula for, 120 
Rectum, abscess of, 297 

extirpation of, 297 

after-care and treatment, 297 
complications following, 299 
extirpation of hemorrhoids, post- 
operative treatment, 293 
Kraske's method, 298 
Mayo's modification. 299 
Murphy's vaginal method, 

298 
postoperative treatment, 
299 
Resection of joints, 418 
Retention of urine after laparotomy, 223 
Retroversion of uterus — 

Alexander's operation for, after- 
care of, 272 
Reverdin's method of skin-grafting, 141 
Rhoades (Thomas L.) — 

on abscess of liver, technic of 

operation for, 208 
after-treatment, 209 
Rochester's method in pneumonia, 49 
Rontgen-rays in postoperative treatment, 

457 

combined method of treat- 
ment with escharotic, 457 

dosage and method of treat- 
ment, 458 

effects of treatment on tis- 
sues, 462 

protection of patients, 467 

technic, 461 

tubes, size and character of, 

,463 
types of curable epithelioma, 

466 
vaginal and rectal tubes, 466 
Wagner's adjustable focus 
tube, 465 
Ruspini's styptic in hemorrhage of liver, 64 

3 2 



Salt solution, normal — 

after laparotomy in general, 227 
hypodermatoclysis, 113 

Kelly's apparatus for, 
114 
in peritonitis, 63 
intravenous, 109 

formula of Locke, 113 
formula used in Hal- 
sted's clinic, 113 
method of administration, 113 
rectal enemata of, 227 
Scrotum, operations on, 310 
Senn (Nicholas) on abdominal drainage in 
septic cases, 254 
amputations, 404 
drainage in general, 254 
empyema, method of drainage 

and after-treatment, 185 
modern treatment of compound 

fractures, 353 
preparation of patients for oper- 
ation, 10 
treatment of septic wounds, 354 
Septicemia (see Postoperative Infection), 36 
Shock, surgical, postoperative, blood-pres 
sure in, 87, 88 
causes of, 85 
character and extent, 85 
general consideration of, 85 
general symptoms, 86 
in operations on brain, 87 
methods to prevent, 87 
treatment of shock as result of 
hemorrhage, 87, 90, 91 
psychic disturbances, 94 
toxic effects of anesthetic, 

93 
Shoulder-joint, excision of, 414 
Silver-foil to prevent adhesions in brain 

surgery, 153 
Skin-grafting, 141 

after-dressings for, 144 
after-treatment in general, 145 
Cargile membrane in, 146 
cutting and application of 

grafts, 143 
essentials for success, 141 
Reverdin's method of, 141 
Thiersch's method of, 142 
transplantation in mass, 146 
preparation of, for operation, 142 
Solutions for use in abdomen, 16 
normal salt, 227 
tap water, 16 
Sphygmomanometer, 88 
Spina bifida, postoperative treatment, 329 
Splints, special — 

Agnew's patella, 380 
ambulatory, 421 
anterior and posterior leg, 422 
Bodine's triangular, after breast 
amputation, 189 



498 



INDEX. 



Splints, special — 

Cabot's wire, 380 
Hodgen's suspension, 424 
Hoppe's universal, 414 
Schaffer's hip, 419 
Thomas hip, 419 
Volkmann's dorsal, for ankle, 
426 
Steam tent in postoperative treatment of 

tracheotomy, 174 
Stomach, postoperative treatment, gastrot- 
omy, 213 
pylorectomy, 213 
Subcutaneous feeding, 120 
Superior maxilla, excision of, 155 

after-treatment of, 156 
Suprapubic drainage-tube, lithotomy, 296 

Stevenson's, 280 
Symphysiotomy, Ayres' hammock for, 332 
general remarks on, 331 
mechanical aids in post- 
operative treatment, 332 

Talipes (vide Club-foot), 413 
Temperature, sudden rise in infection, 36 
traumatic or postoperative, 

35 
Testes, removal of (vide Castration), 311 

Thiersch's method of skin-grafting, 142 
Thigh, amputation of, 380 
excision of, 394 
fracture of, 367 
Thirst after anesthesia, 95 

Semmola's glycerin drink to allay, 
482 
Thoracoplasty (Schede), 184 
Thrombosis, postoperative, causes of, 50 

treatment of, 51 
Thyroid gland, after-treatment, 181 

important technic in re- 
moval of, 180 
myxedema after, 182 
persistent oozing after, 181 
postoperative recurrent 

hemorrhage, 180 
thyroidism following, 182 
Tillmann's paper dressing, 103 
Tongue, excision of, 158 

Kocher's method of after-treat- 
ment, 160 
Kocher's method of dressing after, 

160 
Sedillot-Syme operation, 158 
tetany after, 181 
Treves' method of after-treatment, 

159 
Whitehead's operation, 158 
Trachelorrhaphy, after-treatment, 272 
Tracheotomy, postoperative treatment, 173 
cleaning and removal of 

tube, 173 
dietetics and method of feed- 
ing after, 176 



Tracheotomy, Jacobson's method of after- 
treatment, 175 
of incision, 175 
Trephining, postoperative treatment, 152 
closure of wound, 152 
Keen's method in, 152 
osteoplastic flap (Wagner), 152 
postoperative adhesions and 

method to prevent, 153 
postoperative hemorrhage, 152 
Treves (Sir Frederick) — 

after-treatment of cleft palate, 
164 
' after-treatment of colostomy, 

219 
after-treatment of cystotomy, 

279 
after-treatment of excision of 

shoulders, 415 
after-treatment of wounds, 103 
on after-treatment of abdominal 

section, 234 
preparation of patient for oper- 
ation, 6 
Tuberculosis of epididymis, 312 
Tuberculosis of joints — 

Bier's treatment of, 340 

hip- joint and knee abscesses, 

337 
after-treatment, 338 
Cheyne-Treves' treat- 

ment, 337 
Phelps' treatment of, 339 
iodoform-glycerin injections in, 

340 
Thomas brace in, 344 
traction and splinting in, 344 
Whitman's method of treat- 
ment, 342 
Turck (R. C.) on drainage in pelvic ab- 
scess, 251 
after-treatment, 251 

Umbilical hernia, postoperative treatment, 
266 

Urethrotomy, general remarks on, 300 
external method, 304 
internal method, 303 
postoperative complications, 

305 
extravasation of urine, 

3°5 
treatment of, 305 
Urine, examination of, prior to anesthesia, 

2 
Uterus, operations on (vide Hysterectomy), 
269 

Vagina, operations on (see Perineorrhaphy), 

286 
Vaginal hysterectomy, treatment of, 269 
Veins, varicose, removal of and after-treat- 
ment. Mayo, 233 



INDEX. 



499 



Ventral hernia, postoperative, Andrews' 
method, 265 
causes and treatment of, 263 
Vomiting, postanesthetic, 83 

method of prevention and treat- 
ment, 84 
use of lavage in, 84 

Wiggins on postoperative paresis, 46 
Wounds, general consideration of, 21 

dry method of treatment, 

22 
facial, 107 

irrigation of, during oper- 
ations, 22 
general remarks on, 21 
postoperative drainage 

and dressings of, 21 
superficial aseptic, 29 
suture of, 21 
aseptic, postoperative wound su- 
ture, 21 
in lacerated wounds, 107 
closure of abdominal wounds, 21 
drainage, considerations 
of, 29 
closure of, dressings for, 29 

of postoperative treatment 
in general, 100, 109 



Wounds, closure of, relief of tension in, 21 
Sir Frederick Treves' 
method of treatment, 
103 
granulating, Outten's method of 
treatment, 139 
skin-grafting in, 141 

Reverdin's method, 

141 
Thiersch's method, 
142 
septic or infected, principles gov- 
erning treatment (Da- 
Costa), 106 
Hutchinson (Jno.) treat- 
ment of infected wounds, 

i°5 

Pryor's treatment of septic 
conditions following 
plastic operations, 105 

Senn (Nicholas) on irriga- 
tion of wounds, 

357 
on treatment of sep- 
tic wounds, 354 
Wrist-joint, resection of, 418 

X-ray (see Ront gen-ray), value of, in post- 
operative treatment, 457 



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